HLG HSE FM 016A r00 HSE First Aid Record

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First Aid Record

PERSONAL DETAILS
Name: Address:
Employer: Industry / Trade:
Known Illness including medications: D.O.B: / /

INCIDENT / ACCIDENT DETAILS INJURY / ILLNESS DETAILS


Date/Time:
Location:

Work Process being performed:

Description of incident/accident:
Injury Classification: PD1 PD2 PD3

FIRST AID TREATMENT GIVEN

Date:

ACTION:
Back to Work

Hospital

Doctor / Clinic

Reported to Supervisor
Accident Investigation Report Required (INDICATE LOCATION OF INJURY)

FIRST AID TREATMENT BY MANAGER’S COMMENT


Does incident need
Name: investigating? No Yes In Progress
(Print name of person completing this form) What were the causal factors?

Address:
(Please print)

What immediate controls have been implemented?

Signature: Date: Signature: Date:

DISTRIBUTION: Original to: Project Manager, Copy retained by Medical Attendant.

Page: 1 / 1 Document No.: HLG/HSE/FM/016A Rev.00

Al HABTOOR LEIGHTON GROUP

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