Injury Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Injury Report

• Surname:

• Given Name:

• Date of Birth:

  Date

• Gender:

  Male

  Female
• Address:
  Address

• History of Injury / Illness:

• Allergies:

• Medication:

Observations

• Level of Consciousness (AVPU):
Level of Consciousness Observation

• Time:

  Date

• Alert?

  Yes

  No

  N/A

• Responds to Verbal Stimulus?

  Yes

  No

  N/A

• Responds only to Painful Stimuli?

  Yes

  No

  N/A

• Unresponsive?

  Yes

  No

  N/A

• Pulse:
Pulse Observation

• Time:

  Date

• Rate:

• Description:

• Breathing:
Breathing Observation

• Time:

  Date

• Rate:

• Description:

• Skin:
Skin Observation

• Time:

  Date

• Colour:

Assessment

• Add drawing

  Drawing

• Other Observations:

• Assessment:

• Treatment:

• Follow Up Referral:

  Select Ambulance Medical Centre Own Doctor Other

  • Ambulance
  • Medical Centre
  • Own Doctor
  • Other

• Comments:

• First Aider:

• Position:

• Signature:

  Sign

• Date and Time:

  Date