Title Page
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Reported On
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Prepared by
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Location
General Information
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Name of Employee Requiring First Aid (Last Name, First Name)
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Position - Function (e.g., RSM - Commercial SE)
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Date of First Aid Incident
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Name of Line Manager (Last Name, First Name)
First Aid Kid Checklist
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Check all items that were used to treat first aid incident.
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60ml Isopropyl Alcohol (70% solution)
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Estimate how much was used during first aid. (e.g. 1/4, 1/2, All)
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120ml Hydrogen Peroxide
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Estimate how much was used during first aid. (e.g. 1/4, 1/2, All)
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15ml Povidone Iodine
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Estimate how much was used during first aid. (e.g. 1/4, 1/2, All)
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10g Cotton
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Estimate how much was used during first aid. (e.g. 1/4, 1/2, All)
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Band-Aid (12 pcs)
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How may pieces were used?
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3x3 Gauze Pads
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How many gauze pads were used during first aid?
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2x2 Gauze Pads
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How many gauze pads were used during first aid?
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Gauze Bandage
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Plaster Tape
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Elastic Bandage
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Wet Wipes
Incident Description
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Describe here in detail the incident requiring the application of first aid.
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Was further medical or laboratory tests necessary after the application of first aid?
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Please list down all medical or laboratory tests received as ordered by the doctor.
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Attach here pictures of the incident requiring first aid treament (if available).
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If replacement is being requested due to items expiring, leave the incident description blank.
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Indicate here all first aid kit items and their expiring date (Item - Expiration Date)
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After filling up the form, please e-mail the form to PH.HSE@syngenta.com.
Replacement Request
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Select all the first aid kit items being requested for replacement.
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Isopropyl Alcohol
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Hydrogen Peroxide
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Povidone Iodine
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Cotton
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Band-Aid
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3x3 Gauze Pad
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2x2 Gauze Pad
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Gauze Bandage
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Plaster Tape
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Elastic Tape
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Wet Wipes
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IMPORTANT : Purchase replacements ONLY when you get approval from HSE.
Confirmation Page
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Please confirm that the details in this report are complete and accurate.
