Casualty Name *

First Name

Last Name

Date of Incident *

MM

DD

YYYY

Time of Incident *

Hour

Minute

Second

AM PM

First Aid Equipment *

Check off all equipment used.

None

Ice Pack

Gauze

Medical Tape

Tensor Bandage

Crutches

Triangular Bandage

Responding Staff *

First Name

Last Name

Involved Equipment? *

If equipment was involved be sure to fill out an Equipment Report Form

No equipment involved

Equipment boxed and sealed with date and time and put in electrical room.

Paper Incident Form Filled Out and Filed? *

Yes

Follow-up reminder set in reminders list? *

Yes