Incident Report

Incident Report

This form should be filled out if any type of first aid has been performed (anything more than give a bandaid)
What location are you filling this out for?(Required)

Patient Information

Please enter information for the person receiving First Aid Treatment
Patients Name(Required)
MM slash DD slash YYYY

Incident Information

Please enter all information regarding the incident
MM slash DD slash YYYY
Time of Incident(Required)
:
Time of First Intervention(Required)
:
Time of Medical Support Arrival (if applicable)
:
After treatment, the patient was:(Required)

Charge Person Information

Name of the person providing first aid(Required)

Witness Information

Someone who observed the incident and response, not the charge person
Name(Required)

Form Completed By

Please enter the information for whomever is filling out this form
Name(Required)