Injury/Illness Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Injury/Illness Form

• Date & Time

  Date
• Location
  Address

• Surname

• Given Name

• Date of Birth

  Date

• Gender

  Male

  Female
• Address
  Address

• History of Injury/Illness

• Allergies

• Medication(s)

Observations

• Time

  Date

• Level of Consciousness (AVPU)

  Select (A) Alert Responds to (V) Verbal Stimulus Responds only to (P) Painful Stimuli (U) Unresponsive

  • (A) Alert
  • Responds to (V) Verbal Stimulus
  • Responds only to (P) Painful Stimuli
  • (U) Unresponsive

• Pulse

• Rate

• Description

• Breathing

• Rate

• Description

• Skin (Colour)

• Assessment

  Select Abrasion Burn Contusion Deformity Fracture Haemorrhage Laceration Pain Rigidity Swelling Tenderness

  • Abrasion
  • Burn
  • Contusion
  • Deformity
  • Fracture
  • Haemorrhage
  • Laceration
  • Pain
  • Rigidity
  • Swelling
  • Tenderness

• 

• Other Observations

• Assessment

• Treatment

• Follow Up/Referral

  Select Ambulance Medical Centre Own Doctor Other

  • Ambulance
  • Medical Centre
  • Own Doctor
  • Other

• Please specify:

• Comments

• First Aider (Print)

• Signature

  Sign

• Position

• Date and Time

  Date