• 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.

  • Name of Caualty / Patient

  • Address of Casualty / Patient

  • Occupation of the Casualty / Patient

  • Date of Birth of the Casualty / Patient

2. Details of the Incident.

  • Date and time of the incident.

  • Incident Location

3. Treatment Administered / Advice Given.

  • Treatment Administered / Advice Given:

  • Casualty referred onto other medical staff

  • If referred on please tick appropriate box:


  • Any Comments

5. Signatures

  • Signature of First Aider:

6. E-mail the completed form to:

  • '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

  • Form received by:

  • Date:

  • Action taken:

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