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Health and Safety - First Aid Report
Health and Safety - First Aid Report
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Use this form to report a health/safety incident
Title
A short description to explain the nature of a ticket.
Report a Workplace Injury, Illness, or Exposure
Incident Type
Incident Type
1 - No Injury
2 - First Aid Only
3 - Referred to Medical Aid
4 - Ambulance Rapid Transport
5 - First Aid Follow Up
Patient Type
Employee
Student
Contractor
Visitor
Patient Name - First and Last
Okanagan College I.D. Number
Please enter an OC ID# if known or applicable
Patient Phone Number
Please provide contact information if available
Patient Email Address
Please provide contact information if available
Campus
Kelowna
Penticton
Salmon Arm
Vernon
Other
Other Off-Campus Location
Location where incident occurred (campus, building, room #, area, etc.)
Date and Time of Injury, Illness, or Exposure
(mm/dd/yyyy hh:mm)
Date and Time Reported
(mm/dd/yyyy hh:mm)
Reported To
Description of how the injury, illness, or exposure occurred (what happened)
Description of injury, illness, or exposure (what you see)
Description of the treatment given (what did you do)
Description of Patient Outcome
Name of witnesses
Worker handouts provided
Recommend worker discuss alternate duties with supervisor
No
Yes
First Aid Attendant’s Name
Attach a first aid record
Please scan and attach any hand written first aid records related to this incident.
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Other Fields
Your name
Your first name
Your last name
Your email address