Campus and Community Recreation Club Sports Office
Faculty of Physical Education & Recreation
2-662M Van Vliet Complex
University of Alberta
Faculty of Physical Education and Recreation
FIRST AID AND REPORT FORM
Please note:
- If the injured party is a University staff member carrying out his/her job duties please complete the appropriate WCB forms immediately.
- If the injured party is a University student injured during academic class time, inform the victim that they must complete the appropriate WCB forms at the PER Undergraduate Office (3-100 U. Hall) as soon as possible (within 24-48 hours).
- If additional writing space is required for the First Aid Report Form or for Witness Statements, please use the Incident and Investigation report forms.
PERSINAL INFORMATION
Patient Name: Click here to enter text. Date of Birth: Click here to enter a date.
Male: ☐ Female: ☐ Phone Number: Click here to enter text.
Address: Click here to enter text.
City: Click here to enter text. Postal Code: Click here to enter text.
Report Date: Click here to enter a date. Report Time: Click here to enter text. AM: ☐ PM: ☐
Incident Date: Click here to enter a date. Incident Time: Click here to enter text. AM: ☐ PM: ☐
Incident Location:
☐ Education Gym / ☐ Artificial Turf / ☐ Curling / ☐ North Gym / ☐ Lister Field
☐ Fitness Centre / ☐ Easter Field / ☐ Fitness Centre / ☐ South Gym / ☐ C orbett Field
☐ Main Gym: / ☐ Track / ☐ High Performance Centre / ☐ Competition Gym / ☐ Faculte St. Jean
☐ Pavilion / Other: Enter text. / ☐ Tennis / ☐ Walking Track / ☐ RTF Gym
☐ East Pool
☐ West Pool / Other: Enter text. / ☐ Dance Studio / Other: Enter text.
☐ Studio / Other: Enter text.
☐ Arena
☐ Climbing Wall
☐ Varsity Field
Other: Enter text.
HISTORY/DESCRIPTION OF INCIDENT (What happened to cause injury, the scene when you arrived, be specific).
Click here to enter text.
Medications: Click here to enter text. Allergies: Click here to enter text.
Incident Scene (Describe the scene of the incident. Example: Floor was wet, Floor was clean, Area was dark, Area was well lit, etc):
Click here to enter text.
Cause of Accident:
Equipment Failure: ☐ Facility Issue: ☐ Health of Participant: ☐ Situational: ☐
Other: Click here to enter text.
FIRST AID TREATMENT (Be specific):
Click here to enter text.
Time Administered: Click here to enter text. AM: ☐ PM: ☐
PART OF BODY INJURED:
Head: ☐ / Eye:R: ☐ L: ☐ / Hand:
R: ☐ L: ☐ / Quad:
R: ☐ L: ☐
Face: ☐ / Ear:
R: ☐ L: ☐ / Finger:
R: ☐ L: ☐ / Knee:
R: ☐ L: ☐
Neck: ☐ / Shoulder:
R: ☐ L: ☐ / Ribs:
R: ☐ L: ☐ / Shin:
R: ☐ L: ☐
Abdomen: ☐ / Upper Arm:
R: ☐ L: ☐ / Pelvis:
R: ☐ L: ☐ / Ankle:
R: ☐ L: ☐
Torso: ☐ / Elbow:
R: ☐ L: ☐ / Groin:
R: ☐ L: ☐ / Foot:
R: ☐ L: ☐
Back: ☐ / Forearm:
R: ☐ L: ☐ / Hamstring:
R: ☐ L: ☐ / Toe:
R: ☐ L: ☐
Other: Enter text. / Wrist:
R: ☐ L: ☐
Action Taken:
☐ Ambulance Called ☐ UA Protective Services Called ☐ Referred to Hospital ☐ Referred to Medicentre ☐ Returned to Event
UA Protective Services Contact Time: Enter text. Arrival Time: Enter text. UAPS File Number: Enter text.
Ambulance Arrival Time: Enter text.
CARDIAC ARREST/AED TREATMENT
☐ Arrest Not Witnessed ☐ Arrest Witnessed Time: Enter text. AM: ☐ PM: ☐
CPR Started By: ☐ Bystander Staff Member (name): Enter text. ☐ Police/Firefighter ☐ Other
Time CPR Started: Enter text. Time AED Connected: Enter text. Time of First Shock: Enter text. Number of Shocks Given: Enter text.
PROGRAM TYPE:
☐ Supervised (Academic Class/Instructor/Coach/Monitor/Camp/Intramurals) / ☐ Unsupervised (Recreational) / ☐ Visitor (Spectator)
REFUSAL OF TREATMENT
☐ Please check this box if the injured party refuses treatment. Witness: Click here to enter text.
RELEASE
Time of Release: Enter text. AM: ☐ PM: ☐ Injured Party’s Condition: Enter text.
Left with: ☐ Family Member ☐ Friend ☐ On their own
UAPS (Name and Badge #): Enter text. EMS #: Enter text.
REPORTING INFORMATION
Name of Reporting Individual: Enter text. Position: Enter text.
Work Phone #: Enter text. Signature: Enter text.
Name of Witness 1: Enter text. Witness Statement Attached: ☐
Telephone #: Enter text. Signature: Enter text.
Name of Witness 2: Enter text. Witness Statement Attached: ☐
Telephone #: Enter text. Signature: Enter text.
PLEASE GIVE COMPLETED FORM TO UNIT MANAGER OR SUPERVISOR IMMEDIATELY UPON COMPLETION.
In the event of a serious, life-threatening accident or fatality, IMMEDIATELY contact the DIRECTOR OF CAMPUS AND COMMUNITY RECREATION – FACTULTY OF PHYSICAL EDUCATION AND RECREATION
Protection of Privacy – The personal information requested on this form is collected under the authority of Section 33© of the Alberta Freedom of Information and Protection of Privacy Act and will be protected under Party 2 of that Act. It will be used for the purpose of administering programs within the Faculty of Physical Education and Recreation, including for statistical purposes, evaluation of health and safety programs, and Risk Management purposes.
Note: A copy of this form will be provided to City of Edmonton Emergency Medical Services in the context of cardiac arrests and other medical conditions as necessary, the Fire Department in some cases, and other external bodies as required, depending upon the nature of the injury.