FIRST AID RECORD FORM

PERSONAL DETAILS:

Name:..................................................................... Address:..............................………….............................

Employer:................................................................ Occupation.…....................................……………..........

Known Illness including medications:.......................……………...........................D.O.B........../............./.........

INCIDENT/ACCIDENT DETAILS: INJURY/ILLNESS DETAILS:

Date/time:.............................................………......…. .............................................................................……..
Location:........................................................………. ..............................................................................…….
Work process being performed:.....…….......………..
.......................................................................………. INCIDENT OUTCOME:
Description of incident/accident:...................………. Class I  Class II  Class III 
………………………………………………………. Causes: ..................................................................……
………………………………………………………. …………………………………………………………

FIRST AID TREATMENT:

.......…............................................………................

.................................................................………......

Date:....../....../......
__________________________________________

ACTION: Back to Work 

Hospital 
Doctor/Clinic 
Reported to Supervisor 
Incident Report Required 
(INDICATE LOCATION OF INJURY)

Name:...........................................................……... MANAGER'S COMMENT:

(print name of person completing this form) Yes No
Has incident been investigated?  
Address:.........................................................…….
(please print) Has Corrective Action been
.......................................................................……. implemented?  

Site Address: ……………………………….……. Has incident investigation report

……………………………………………………. been completed?  

..............................……………. ..................................................... ......................

(Signature) Signature Date

To be completed for all first aid treatments. Original forwarded to the SHE Coordinator at the end of each month.

PT. Cipta Kridatama Page 1 of 1