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First Aid Report <br /> Date of Report: Name of Working Partner: <br /> Date&Time Injury/Illness occurred: <br /> Job Title: <br /> Time In: Experience of Working Partner: <br /> Time Out: <br /> How Long on This Site: <br /> m ,X.. <br /> Employee Name: <br /> SS#: Subcontractor: <br /> Date of Hire: Foreman: <br /> Job Title: Supervisor: <br /> Experience: <br /> How Long on This Site: <br /> Work Location/Area: <br /> Location of injury/illness: <br /> Description of injury/illness: <br /> Description of first aid administered: <br /> Allergies: <br /> Physician referral? (Y) yes, (N) no, or(U) unknown <br /> Return to work? (Y) yes (N) no, or(U) unknown <br /> Tetanus up to date? (Y) yes, (N) no, or(U) unknown <br /> Restricted duty? (Y) yes, (N) no, or(U) unknown <br /> Recordable? (Y) yes, (N) no, or(U) unknown <br /> Workman's comp? (Y) yes, (N) no, or(U) unknown <br /> Any related previous injury/illness? (Y) yes, (N) no, or(U) unknown <br /> If yes, describe: <br /> Name of person/persons giving treatment: <br /> Reviewed by: <br /> Date: The employee is being released to return to <br /> work without restrictions. <br /> Time: <br /> Date of injury: Please sign and return to the CB&I Safety <br /> office• <br />