Title Page

  • Event Name

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Full Name

  • Date of Birth

  • Sex

  • Occupation

  • Contact number

  • Home address

  • Email address


  • Type of injury or disease (e.g burn)

  • Part/s of the body affected

  • Date and time of occurrence

  • Was medical treatment given?

  • Treatment provided

  • Provider

  • Date and Time of treatment

  • How did the injury happen?


  • Name and Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.