First Aid Treatment Log Form

Introduction: How to Use This Tool

People who provide first aid treatment at your workplace should complete a registry or log listing the key details of the case after each treatment episode—or a worker’s refusal to be treated and/or transported for treatment. In addition to serving as an important medical record, completion of logs is critical to documenting compliance with the workplace first aid requirements of your jurisdiction. The Model Log below is fairly generic and easily adaptable to the particular first aid treatment procedures and requirements of your own workplace.

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FIRST AID TREATMENT LOG

Instructions: This Log must be completed by the treating first aid attendant after each episode in which a worker is provided first aid treatment at ABC Company facilities or work sites as well as in instances in which a worker is offered first aid treatment or transport but refuses to accept it. All parts of this Log must be completed, including those regarding post-treatment actions. Completed forms must be retained for a minimum of three years from the date of treatment.

PART 1: TREATMENT EPISODE

Date of Injury/Illness:   __________________________________________________

Time of Injury/Illness:   __________________________________________________

Date of Injury/Illness Was Reported (if different from above): __________________________________

Time of Injury/Illness Was Reported (if different from above):__________________________________

Location at Worksite Where Injury/Illness Occurred:   _________________________________________

Description of Injury/Illness: _____________________________________________________________

How Injury/Illness Occurred: _____________________________________________________________

Name of Injured Worker:   ____________________              Position:   ___________________________

Name of First Aid Provider: ____________________________Title: _____________________________

Qualifications of Provider (e.g., standard or advanced first-aid attendant): _________________________

Names of Witnesses:_____________________________     Telephone:  ________________________

Was first aid treatment provided to the injured/ill worker’ (  ) Yes (  ) No

_____________________________________________________________________________________

Describe the first aid treatment provided. If the worker was offered but refused treatment, complete and have the worker sign the Refusal Acknowledgement at the bottom of this Form: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Was the injured/ill worker advised to seek further medical treatment’ (  ) Yes  (  ) No

Explain what the worker was advised and how he/she responded. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Was the injured/ill worker offered immediate transportation to the nearest medical facility for treatment of his/her injuries/illness at Company expense’ (  ) Yes  (  ) No

Explain what the worker was offered and how he/she responded. If the worker was offered but refused transport, complete and have the worker sign the Refusal Acknowledgement at the bottom of this Form:  ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signatures:

First Aid Provider: ___________________________________________  Date: __________________

Injured Worker (obtain signature, if possible): _______________________ Date: ­­­­­­­­­­­­­­­______________

Witness 1: _______________________________________________ Date: ___________________

Witness 2: _______________________________________________ Date: ___________________

Witness 3: _______________________________________________ Date: ___________________

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APPENDIX: ACKNOWLEDGEMENT OF WORKER REFUSAL

Instructions: This Appendix must be completed when a worker is offered but refuses first aid treatment and/or emergency transport to the nearest hospital or medical facility at Company expense for purposes of receiving treatment. If the refusing worker will not sign the acknowledgement, be sure to have at least one witness sign to acknowledge that he/she witnessed the refusal.

Worker Refusal of Offered Medical Treatment and/or Transportation

I, (worker’s name—printed) ____________________________________________________,  acknowledge that first aid attendants or other representatives of the Company, my employer, offered me medical treatment and explained my right to be transported to a nearby medical facility for treatment of my workplace injury or illness at Company expense, but that I voluntarily and knowingly refused the offered treatment and/or transportation, as is my legal right to do.

Signed_______________________ (Worker name)  _____________________(Date)_______________

Worker was offered but refused transportation to a medical facility for treatment and refused to sign the form acknowledging such refusal:

Signed __________________________ (First Aid Provider name)________________ (date)__________

Signed __________________________ (Witness name)________________ (date)__________

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PART 2: POST-TREATMENT ACTION

Actions taken in response to this Log:  ________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

Indicate whether copies of this Log were provided to:

Joint Health and Safety Committee*: (   ) Yes (  ) No

Date: ______________   Received By: _________________________________________________

Health and Safety Representative*: (   ) Yes (  ) No

Date: ______________

Others*: (   ) Yes (  ) No

Describe: _________________________________________________   Date: ______________

* Was the victim’s name and other identifying information redacted from copies of Logs disclosed to third parties’ (  ) Yes   (   ) No     If not, explain why not: __________________________________________________________________________________________________________________________________________________________________________

Was any corrective action taken’ (  ) Yes   (   ) No     Date: ____________________________________

Describe corrective actions taken or reasons for not taking corrective actions:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________