Date & Time of Injury or Illness:
Work Area Location Where Injury Took Place:
Description of Events:
Was a Hazard Assessment completed?
Was first aid provided?
Name of First Aider:
- Emergency First Aider
- Standard First Aider
- Advanced First Aider
- Emergency Medical Technician – Paramedic
- Emergency Medical Technician – Ambulance
- Emergency Medical Technician
- Emergency Medical Responder
Description of Injury or Illness:
I hereby certify that all information is accurate and that an actual inspection was conducted as per company policy.