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First Aid Assessment Worksheet Template

This document is a first aid assessment worksheet that is used to evaluate workplace hazards and determine the appropriate level of first aid services required. It collects information such as the workplace name, hazard rating, typical injuries that may occur, travel time to the hospital, number of employees, and barriers to medical treatment. Based on the assessment results, it recommends the necessary first aid supplies, number and level of first aid attendants required, and any transportation needs to ensure workers can access appropriate medical care if injured on the job.

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kave4923
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600 views1 page

First Aid Assessment Worksheet Template

This document is a first aid assessment worksheet that is used to evaluate workplace hazards and determine the appropriate level of first aid services required. It collects information such as the workplace name, hazard rating, typical injuries that may occur, travel time to the hospital, number of employees, and barriers to medical treatment. Based on the assessment results, it recommends the necessary first aid supplies, number and level of first aid attendants required, and any transportation needs to ensure workers can access appropriate medical care if injured on the job.

Uploaded by

kave4923
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

First Aid Assessment Worksheet

1.

Name of workplace: ____________________________________________


Conduct a separate assessment for each identified workplace (see flow chart Step 1)

2(a) Hazard rating on Assigned Hazard Rating List L ___ M ___ H ___
2(b) Job functions, work processes and tools

Typical of industry? Yes ____ No ____


2(c) Types of injuries that can potentially occur
Typical of industry? Yes ____ No ____
2(d) Rating adjustment: if hazard rating is adjusted, provide documentation.
Overall workplace hazard rating
3(a) Surface travel time to hospital

____ M

____ H

____

_______ greater than 20 minutes


_______
20 minutes or less

4(b) Total number of workers per shift ______ (include dispatched workers
and workers in lodgings)

5(f) Barriers to reaching medical treatment

ASSESSMENT RESULTS
(different shifts may require different first aid services)
5(a) Supplies/equipment/facilities required _________________________________________
_______________________________________________________________________________
5(c) Number and level of first aid attendants _________________________________ ______
5(e) Transportation needs _______________________________________________________

Date: _________________ Change in Business Operations: _____________________


Consulted (health and safety committee, worker representative, others):
______________________________________________________________________
Name: _________________________ Signature: _____________________________

RESET

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