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    (NAI-HSE-014) FA AND MT Form

    Uploaded by

    Anthony etienam
    Time: Signature: Date:

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    (NAI-HSE-014) FA AND MT Form

    Uploaded by

    Anthony etienam
    31 views1 page
    Time: Signature: Date:

    Original Title

    [NAI-HSE-014] FA AND MT Form

    Copyright

    © © All Rights Reserved

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    DOC, PDF, TXT or read online from Scribd

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    Time: Signature: Date:

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    31 views1 page

    (NAI-HSE-014) FA AND MT Form

    Uploaded by

    Anthony etienam
    Time: Signature: Date:

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    Document Number: NAI-HSE-014

    Project Name /No :


    Project manager: Date:

    FIRST AID TREATMENT / MEDICAL TREATMENT FORM


    Details of the person receiving treatment

    Surname:_________________________________________ Given Names:________________________ Date of Birth: _____________ Sex: M F


    Status: Academic Staff:  General Staff:  Student:  Contractor / Employed by Contractor:  Visitor: 
    Staff / Student: Number: _________________________Department:___________________________________________________________________
    If staff: Job Title:___________________________________ Continuing:  Casual:  Supervisor: ________________________________
    If Contractor or employed by contractor: Name and address of Contractor: If Visitor: Address:

    __________________________________________________________________________________________________________________________________________
    Details of the Illness/Injury
    Date:________________________________ and Time:___________________ am/pm

    Where did the event happen? Be specific, e.g. room and building _____________________________________________________________________

    Witness (if appropriate)_____________________________________________________________________________________________________________________


    History of Illness/Injury

    __________________________________________________________________________________________________________________________________________

    __________________________________________________________________________________________________________________________________________

    __________________________________________________________________________________________________________________________________________
    Time
    Observations Assessment

    Level of Consciousness
    Fully Conscious Abrasion
    Drowsy Burn
    Unconscious Contusion
    Breathing Laceration
    Rate Pain
    Description Rigidity
    Skin Swelling
    Colour Tenderness
    Other Observations

    Assessment

    __________________________________________________________________________________________________________________________________________

    __________________________________________________________________________________________________________________________________________
    Treatment

    __________________________________________________________________________________________________________________________________________

    __________________________________________________________________________________________________________________________________________

    Follow Up/Referral - None  Nurse  Doctor  Ambulance  Hospital  Other ________________________________________


    Outcome: Continued work/study  Returned next day Absent more than 1 day Unknown  Admitted to hospital? Yes  No 
    Comments

    __________________________________________________________________________________________________________________________________________
    All accidents and workplace injuries should be
    First Aider: Time: reported by the person concerned to their
    supervisor and an Accident and Hazard Report
    Signature: Date: completed.

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