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