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First Aid Report Form
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* Indicates required question
Employee Name
*
Your answer
Time of Injury
*
Time
:
AM
PM
Date of Injury
*
MM
/
DD
/
YYYY
Time Reported
*
Time
:
AM
PM
Date Reported
*
MM
/
DD
/
YYYY
Description of Injury/Illness
*
Your answer
Where injury occurred
*
Your answer
Cause of Injury or Illness
*
Your answer
First aid provided
*
Yes
No
First Aid Provider Name(s)
*
Your answer
Level of Training
*
Your answer
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