Sample Workplace First Aid Incident Form Page 3

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FOLLOW-UP NOTES
OUTCOME
Return to Work
Destination:
Return to Activity
Home
Comments:
To Physician
To Hospital
Other:
By:
Private Car
Taxi
Air Transport
Paramedics (Unit #:
)
Other:
RESPONDER 1
NAME
SIGNATURE
TIME
DATE
RESPONDER 2
NAME
SIGNATURE
TIME
DATE
PATIENT
NAME
SIGNATURE
TIME
DATE
Comments: ________________________________________________________________________________
Sample Workplace First Aid Incident Form
Page 3 of 4

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