First Aid Record — District of Sooke

To be completed by the first aid attendant for every injury, exposure, or illness treated at work. This record is kept by the employer for 3 years. Do not submit first aid records to WorkSafeBC unless asked to do so.

Worker details

First and last name Please enter the worker's name.

Occupation Please enter the worker's occupation.

Employee's birth date

Department

The incident

Date of injury, exposure, or illness Please enter the date.

Time of injury, exposure, or illness Please enter the time.

Initial reporting date Please enter the reporting date.

Initial reporting time Please enter the reporting time.

Location of incident Address is possible.Please describe where it happened.

What happened

Description of how the injury, exposure, or illness occurred What happened?Please describe how it occurred.

Description of the nature of the injury, exposure, or illness What did you see? (i.e., signs and symptoms)Please describe the signs and symptoms.

Description of the treatment given What did you do?Please describe the treatment given.

Witness 1

Witness 2

This record is stored with OHS and retained for 3 years as required by WorkSafeBC. A sequence number is assigned automatically on submission.

Sign off

First aid attendant's name (type your full name) Please type your full name to sign.

Date signed Please enter today's date.

Patient's signature (type full name)Leave blank if the worker is unable to sign at this time.

I confirm this record is accurate to the best of my knowledge, and typing my name above constitutes my signature as first aid attendant.

Record submitted

Thank you. This first aid record has been filed with OHS.

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