Sequence number
Name Occupation
Date of injury or illness
(yyyy-mm-dd) Time of injury or illness (hh:mm)
a.m. r p.m. r
Initial reporting date and time (yyyy-mm-dd)
a.m. r p.m. r
Follow-up report date and time (yyyy-mm-dd)
a.m. r p.m. r
Initial report sequence number Subsequent report sequence number(s)
(What happened?)
(What you see — signs and symptoms)
(What did you do?)

1. 2.
(return to work/medical aid/ambulance/follow-up)
Provided worker handout Yes r No r A form to assist in return to work and follow-up
Alternate duty options were discussed Yes r No r was sent with the worker to medical aid Yes r No r
First aid attendants name (please print) First aid attendants signature
Patient’s signature


(R02/08) Page 1 of 1
This record must be kept by the employer for three (3) years.
This form must be kept at the employer’s workplace and is not
to be submitted to WorkSafeBC.
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