Injury Report.xlsx

	A	F	I	J	N	T	V	Y
1	CONFIDENTIAL							Ver 1.2
2	CONFIDENTIAL							Ver 1.2
3	ACCIDENT AND INJURY REPORT
4	Date	Address/Location					Time of Incident
5	Date	Address/Location					Time of Incident
6	Patient's Family Name		Patient's Given Name(s)			Date Of Birth
7	Patient's Family Name		Patient's Given Name(s)			Date Of Birth
8	Patient's Home Address					Patient's Phone No.
9	Patient's Home Address					Patient's Phone No.
10	Patient's Allergies?				Patient Medications?
11	Patient's Allergies?				Patient Medications?
12	Discription of the Incident (what happened, where, and when?)
13
14
15
16
17	Witness' Family Name		Witness' Given Name			Witness' Phone No.
18	Witness' Family Name		Witness' Given Name			Witness' Phone No.
19				Description of Injury
20
21
22
23
24
25				Treatment Administered
26
27
28
29
30
31	Relivent Medical History (conditions, diagnosies and injuries)
32
33
34	Refused Treatment? (Witness Name and Signature)				Discharged How? (Ambulance, Returned to activity, hospital, Other)
35	Refused Treatment? (Witness Name and Signature)
36	First Aider Name				First Aider Signature
37	First Aider Name				First Aider Signature
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100