First Aid Report Form

July 12, 2011

A First aid report form is used to provide information of an injury/accident happened at any workplace in which an employee was affected and given the first aid treatment. This report form is usually prepared by work security officer to keep a record of injuries at workplace and to make arrangement for compensation if necessary.

Sample First-aid Report Form



General Information


Name of Workplace____________ Title of Project____________

Address_____________ Phone____________ Email_________

Supervisor Name_________ Phone___________


First-Aid Report Information


Date of incident, when first aid was given___/___/____ Time/Hours________

Name of Person given the first-aid___________   Age_______ Sex________


Address__________ Phone___________

Causes of injury__________

The activities of person at the time of injury___________

First witnesses of injury and first-aid________________

Brief description of circumstances in which first aid was given__________________

Nature of injury: Serious/Non Serious______________

First –aid given for: Describe the injury/suffering________________

Any medical treatment provided to affected person after first-aid_________

Name the Hospital/Physician_____________ Address_________ Phone__________

Extra Remarks_______________

Signature_____________ Date of Report Submission____/___/____


Download First Aid Report Form in Word Format

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