D2C First Aid Report v1

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Information

• Name of Worker

• Occupation of Worker

• Time and date of injury or illness

  Date

• Time and date reported

  Date

• Initial report document number

• Follow-up report document number

• Add signature

  Sign

• Description of how the injury, exposure, or illness occurred (What happened?)

• Description of the nature of the injury, exposure, or illness (What you see — signs and symptoms)

• Description of the treatment given (What did you do?)

• Was it witnessed?

  yes

  no

• Please list witnesses and what company they work for

• The worker will:

  Return to work

  Medical Aid

  Ambulance

  Follow-up

• Make sure the worker knows appropriate followup for management of the injury, provide a handout if needed.

• Is the worker on modified duties as a result of the accident?

  yes

  no

• What are the limitations of the modified duties?

• Has this been explained to the worker?

  yes

  no

• Make sure the worker understands how to work with their injury without hurting themselves.
  If there is any confusion call Trevor Walper (Safety Coordinator) at 604-355-0464.

• What are the concerns being followed up on?

• Are there any limitations that will prevent the worker from conducting their work before you follow up with them?

  yes

  no

• Place worker on modified duties

• Planned date and time of follow-up

  Date

• Please phone Trevor Walper (Safety ) at 604-355-0464 if you need help transporting the patient to the hospital or clinic.

• How was the patient transported to medical aid?

• What is the location of the medical aid the patient was referred to? (if known)

• Please notify Trevor Walper (Safety Coordinator) immediately at 604-355-0464.
  Only transport by ambulance if it is an emergency.

• What hospital was the patient transported to? (if known)

• First aid attendant

  Sign

• Patient

  Sign

• After the form is completed please save it as a pdf and forward to Trevor Walper (Safety Coordinator) at t.walper@div2contracting.com
  If this is the result of an accident/incident or the repercussions of what caused it could have been severe please phone Trevor Walper at 604-355-0464 to discuss accident/incident investigation.