Appendix D — First Aid Treatment Form
First Aid Treatment Form
3F Construction LLC • 202 N. Justine Street, Chicago, IL 60607 • (312) 296-4855
Instructions: completed by the treating first-aid attendant after each episode in which a worker receives first aid at a 3F Construction site — including instances in which a worker is offered first-aid treatment or transport and refuses it.
Date of injury/illness ________________________ Time ______________
Date reported (if different) ____________________ Time reported ______________
Location at worksite where injury/illness occurred _____________________________________________
Description of injury/illness ____________________________________________________________
How the injury/illness occurred __________________________________________________________
Injured worker ______________________________ Position ____________________
First-aid provider __________________________ Title / qualifications ________________________
Witnesses ________________________________ Telephone __________________
Was first aid provided? ☐ Yes ☐ No Advised to seek further medical treatment? ☐ Yes ☐ No Offered transport to medical facility at company expense? ☐ Yes ☐ No
Describe treatment provided / what the worker was advised or offered and the response:
______________________________________________________________________________________
______________________________________________________________________________________
Refusal acknowledgment — I was offered first-aid treatment and/or transport and declined it:
Worker signature __________________________________ Date ________________
First-aid provider signature ______________________________ Date ________________
Witness signature __________________________________ Date ________________