Title Page
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Conducted on:
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Building Name:
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Building Address:
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Injured Worker:
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Supervisor:
Injury Information
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Date & Time of Injury or Illness:
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Work Area Location Where Injury Took Place:
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Description of Events:
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Was a Hazard Assessment completed?
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Was first aid provided?
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Name of First Aider:
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First Aider Qualifications:
- Emergency First Aider
- Standard First Aider
- Advanced First Aider
- Nurse
- Emergency Medical Technician – Paramedic
- Emergency Medical Technician – Ambulance
- Emergency Medical Technician
- Emergency Medical Responder
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Treatment:
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Description of Injury or Illness:
Signature
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I hereby certify that all information is accurate and that an actual inspection was conducted as per company policy.
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Crew Manager's Signature:
