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PHC Accident Report Form
To be completed every time that first aid is carried out from a simple ice pack/ plaster to a broken or hospital visit.
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* Indicates required question
Name of person completing the form
*
Your answer
Contact details (Contact number) of person completing the form
*
Your answer
Name of the injured person
*
Your answer
Date of Birth of injured person
*
MM
/
DD
/
YYYY
Contact details of injured person including number and address
*
Your answer
Witness Name and Contact details.
*
Your answer
Where did the accident happen?
*
Your answer
Date of the accident
*
MM
/
DD
/
YYYY
Details of the injury - Location, type.
*
Your answer
First aid carried out - including items used from first aid kit
*
Your answer
Was further medical treatment needed?
*
No
Yes - Visit to GP
Yes - Walking centre/ minor injuries
Yes - A & E
Yes - Dentist
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