First Aid Record Form

Page 1 of 1 (R15/05) 55B23
First Aid Record
This record must be kept by the employer for three (3) years. This form
must be kept at the employer’s workplace. Do NOT submit to WorkSafeBC.
Sequence number
Name
Occupation
Date of injury or illness (yyyy-mm-dd) Time of injury or illness (hh:mm)
a.m. p.m.
Initial reporting date and time (yyyy-mm-dd) (hh:mm)
a.m. p.m.
Follow-up report date and time
(yyyy-mm-dd) (hh:mm)
a.m. p.m.
Initial report sequence number Subsequent report sequence number(s)
Description of how the injury, exposure, or illness occurred (What happened?)
Description of the nature of the injury, exposure, or illness (What you see — signs and symptoms)
Description of the treatment given (What did you do?)
Name of witnesses
1. 2.
Arrangement made relating to the worker (return to work/medical aid/ambulance/follow-up)
Provided worker handout Yes No
Alternate duty options were discussed Yes No
A form to assist in return to work and follow-up
was sent with the worker to medical aid
Yes No
First aid attendant’s name (please print)
First aid attendant’s signature
Patient’s signature
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