OCCUPATIONAL FIRST AID
PATIENT ASSESSMENT
DATE AND TIME OF ILLNESS / INJURY
AM / PM
DATE AND TIME REPORTED TO FIRST AID
AM / PM
TIME OF ARRIVAL AT FIRST AID (WALK IN)
AM / PM
TIME ON SCENE (IF APPLICABLE)
AM / PM
EMPLOYEE NAME
DATE OF BIRTH
D
M
EMPLOYEE’S DOCTOR
Y
EMPLOYER NAME
EMPLOYER PHONE NUMBER
CONTACT PERSON
GLASGOW COMA SCALE
EYE OPENING RESPONSE
BEST VERBAL RESPONSE
BEST MOTOR RESPONSE
4
3
2
1
5
4
3
2
1
6
5
4
3
2
1
SPONTANEOUSLY
SPEECH
TO PAIN
NO RESPONSE
PATIENTS CHIEF COMPLAINT
ORIENTED
CONFUSED
INAPPROPRIATE WORDS
INCOMPREHENSIBLE SOUNDS
NO RESPONSE
VITAL SIGNS
TIME
OBEYS COMMANDS
LOCALIZES PAIN
WITHDRAWS FROM PAIN
FLEX TO PAIN (DECORTICATE)
EXTENDS TO PAIN (DECEREBRATE)
NO RESPONSE
TIME
TIME
TIME
RESPIRATIONS
MECHANISM OF INJURY / HISTORY OF ILLNESS
PULSE
E
LOC / GCS
PHYSICAL FINDINGS
PUPIL SIZE &
REACTION
+ / SKIN
TOTAL
V
E
TOTAL
V
M
L
R
M
L
E
TOTAL
V
M
L
R
E
TOTAL
V
M
L
R
R
ALLERGIES
PLEASE MARK INJURED OR EXPOSED AREA
MEDICATIONS
INTERVENTIONS (PLEASE CHECK)
❐ AIRWAY CLEARED
❐ MAINTAINED
❐ VENTILATED
❐ PKT. MASK
❐ CONTROLLED BLEEDING
❐ OROPHARYNGEAL AIRWAY
❐ BVM
❐ OXYGEN ADMINISTERED
LPM__________
DEFINITIVE TREATMENTS (PLEASE CHECK)
❐ TRACTION
❐ SPLINTED
❐ SPINAL IMMOBILIZATION
❐
IMMOBILIZED
❐ ADDITIONAL TREATMENTS (PLEASE EXPLAIN)
RECOMMENDATIONS
❐ RETURN TO WORK
❐ FIRST AID FOLLOW UP
❐ MEDICAL AID
TRANSPORTED BY (PLEASE CHECK)
❐ ETV
❐ INDUSTRIAL AMBULANCE
❐ AIR EVACUATION
CHANGES IN PATIENTS CONDITION (PLEASE EXPLAIN)
❐ B.C. AMBULANCE SERVICE
❐ OTHER (PLEASE EXPLAIN)
F.A.A. NAME (PLEASE PRINT)
F.A.A. SIGNATURE
OFA CERTIFICATE #
OFA LEVEL
❐ 1
NAME OF WITNESSES (PLEASE PRINT)
EMPLOYER MAILING ADDRESS
EMPLOYEE SIGNATURE
CITY / TOWN
55M60 (R01/06)
❐ TE
❐ 2
❐
3
STREET / AVENUE
POSTAL CODE