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What was the condition of the injured/ill party, when you arrived on the scene?
What is the actual injury?
Was First Aid administered?
If yes, who administered it?:
Was more than First Aid required?
If yes, describe
Was professional medical attention declined?:
If yes, who declined it?
Describe Medical attention given, if any:
Was injured/ill party taken to the Hospital?:
If yes, Name & Address of Hospital:
If the injured/ill party left on their own, did they say they will see a doctor?
If Yes, Name & Address of Physician:
What was the condition of the injured/ill person when they left your premises?: