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First Aid Report Formet

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GANESH
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48 views1 page

First Aid Report Formet

Uploaded by

GANESH
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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WINGTECH MOBILE COMMUNICATIONS

INDIA PVT LTD


EMPLOYEE FIRST AID/INJURY REPORT
Instructions: Employees shall use this form to prepare all work to related injury, illness or near-miss events
(which could have cause injury or illness)- no matter how minor. This help us to identify and correct hazards before
they cause serious injuries. This form shall be completed by employee/supervisor as soon as possible and given to
the Area in-charge or safety officer for further action.

I am reporting a work related-(mark √):- 1-Injury 2-Illness 3-Near-miss


Name of Employee:-
Job title:-
Have you told to your supervisor about this injury/near-miss? ( fill mark √):- Yes No
Date of Injury/near-miss Time of Injury/near-miss:-

Name of witness( if have any):-

Where, Exactly, did it happen󠅄?

What were you doing at that time?

Describe step by step what led up to the injury/near-miss(continue on the back if necessary):-

What could have done to prevent this injury/near-miss?

Mention what part of your body were injury?

Did you see a doctor about this injury/illness? ( fill mark √):- Yes No
If yes, whom did you see? Doctor's mobile no.

Date:- Time:-
Has this part of your body injured before? ( fill mark √):- Yes No

If yes, when? Supervisor:-

Person Sign:- Date/Time:-


Area Supervisor Sign:- Date/Time:-

Sign Safety officer (Contractor):-

Sign EHS(Wingtech/CCTEB):-

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