Title Page
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This form is to be used ONLY by a University First Aider when any treatment or advice is offered to a casualty.
1. Details and Occupation of the Casualty / Patient.
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Name of Caualty / Patient
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Address of Casualty / Patient
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Occupation of the Casualty / Patient
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Date of Birth of the Casualty / Patient
2. Details of the Incident.
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Date and time of the incident.
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Incident Location
3. Treatment Administered / Advice Given.
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Treatment Administered / Advice Given:
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Casualty referred onto other medical staff
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If referred on please tick appropriate box:
4. Comments
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Any Comments
5. Signatures
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Signature of First Aider:
6. E-mail the completed form to:
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'Export' the completed form directly by e-mail to:
Securityservicemanagers@lboro.ac.uk and hse@lboro.ac.uk and security@lboro.ac.uk
To be completed by the University Health and Safety Service
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Form received by:
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Date:
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Action taken:
