FIRST AID INVENTORY LIST TEMPLATE

EMPLOYEE NAME:	TITLE / ROLE:	DATE OF REPORT:
EMPLOYEE SIGNATURE:	LENGTH OF TIME IN CURRENT ROLE:	DATE OF INCIDENT:
LOCATION OF INCIDENT:	TIME OF INCIDENT:

RESULT OF ACCIDENT / INCIDENT	INCIDENT INFORMATION
HEAD	LEFT	RIGHT	INCIDENT DESCRIPTION
FACE	SHOULDER
NECK	ARM PIT
UPPER BACK	UPPER ARM
LOWER BACK	LOWER ARM	TASKS LEADING TO INCIDENT
CHEST	ELBOW
ABDOMEN	WRIST	ADDITIONAL INFO
PELVIS / GROIN	HAND
LIPS	BUTTOCKS	OSHA REPORTING
TEETH	HIP
TONGUE	THIGH	WITNESS NAME AND CONTACT
NOSE	LOWER LEG
FINGERS	KNEE
TOES	ANKLE
OTHER:	EYES
OTHER:	EARS

VERIFICATION
SUPERVISOR NAME:	REPORTED TO:	DATE OF REPORT:
SUPERVISOR SIGNATURE:	BUREAU:	WORK UNIT:
ADDITIONAL INFO:

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