Minor Injuries - Investigation - First Aiders

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Date of Incident:

  Date

• Time of Incident:

  Date

• Name of Person Involved:

• Company No:

• Age:

• Occupation:

• Department:

1.TYPE OF INJURY

1.1. Injury / Incident Classification

• Clinic Assistance

  Yes

  No

  N/A

• First Aid Assistance

  Yes

  No

  N/A

1.2. Part of Body Affected:

• Neck

  Yes

  No

  N/A

• Eye

  Yes

  No

  N/A

• Head

  Yes

  No

  N/A

• Back

  Yes

  No

  N/A

• Arm

  Yes

  No

  N/A

• Hand

  Yes

  No

  N/A

• Fingers

  Yes

  No

  N/A

• Leg

  Yes

  No

  N/A

• Feet

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• undefined

1.3. Side:

• Left

  Yes

  No

  N/A

• Right

  Yes

  No

  N/A

• Both

  Yes

  No

  N/A

Finger injuries:

• Thumb

  Yes

  No

  N/A

• Index

  Yes

  No

  N/A

• Middle

  Yes

  No

  N/A

• Ring finger

  Yes

  No

  N/A

• Small Finger

  Yes

  No

  N/A

1.4. Effect on person:

• Sprain

  Yes

  No

  N/A

• Wound

  Yes

  No

  N/A

• Fracture

  Yes

  No

  N/A

• Electric Shock

  Yes

  No

  N/A

• Burns

  Yes

  No

  N/A

• FB Eye

  Yes

  No

  N/A

• Amputation

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

2. INCIDENT DESCRIPTION: (BRIEF)

• undefined

3.1. CAUSE OF INCIDENT

• Unsafe Act

  Yes

  No

  N/A

• Unsafe Conditions

  Yes

  No

  N/A

• Accident

  Yes

  No

  N/A

• Negligence

  Yes

  No

  N/A

3.2. RESULT

• Fit to resume work

  Yes

  No

  N/A

• Sent to Clinic

  Yes

  No

  N/A

• Send Home

  Yes

  No

  N/A

• Temporarily Disabled

  Yes

  No

  N/A

• Name & Surname of First Aider

• Signature:

  Sign

• Name & Surname Injured Person

• Signature:

  Sign

• Date:

  Date

REFUSAL TO ACCEPT FIRST AID AND/ OR MEDICAL TREATMENT:

• Name & Surname Team Leader

• Signature

  Sign

• Date

  Date

• Name & Surname SHE REP

• Signature

  Sign

• Date

  Date

• Name & Surname (HOD)

• Signature

• Date

  Date