Document Number: NAI-HSE-014

Project Name /No :

Project manager: Date:

FIRST AID TREATMENT / MEDICAL TREATMENT FORM

Details of the person receiving treatment

Surname:_________________________________________ Given Names:________________________ Date of Birth: _____________ Sex: M F

Status: Academic Staff:  General Staff:  Student:  Contractor / Employed by Contractor:  Visitor: 
Staff / Student: Number: _________________________Department:___________________________________________________________________
If staff: Job Title:___________________________________ Continuing:  Casual:  Supervisor: ________________________________
If Contractor or employed by contractor: Name and address of Contractor: If Visitor: Address:

__________________________________________________________________________________________________________________________________________
Details of the Illness/Injury
Date:________________________________ and Time:___________________ am/pm

Where did the event happen? Be specific, e.g. room and building _____________________________________________________________________

Witness (if appropriate)_____________________________________________________________________________________________________________________

History of Illness/Injury

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Time
Observations Assessment

Level of Consciousness
Fully Conscious Abrasion
Drowsy Burn
Unconscious Contusion
Breathing Laceration
Rate Pain
Description Rigidity
Skin Swelling
Colour Tenderness
Other Observations

Assessment

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Treatment

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Follow Up/Referral - None  Nurse  Doctor  Ambulance  Hospital  Other ________________________________________

Outcome: Continued work/study  Returned next day Absent more than 1 day Unknown  Admitted to hospital? Yes  No 
Comments

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All accidents and workplace injuries should be
First Aider: Time: reported by the person concerned to their
supervisor and an Accident and Hazard Report
Signature: Date: completed.