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Injury Assessment Form Template
Document injuries quickly and clearly with a structured assessment form for medical, safety, or legal records.
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Injury Assessment Form Template
[Organization / Employer / School / Program Name]
[Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Email: [Email Address]
1. Injured Person Information
Full Name: [First, Middle, Last]
Date of Birth: [MM/DD/YYYY]
Age: [Age]
Gender: [Gender]
Role (check or describe):
Employee
Student / Child
Athlete / Participant
Visitor / Customer
Other: [Describe]
Parent / Guardian Name (if applicable): [Name]
Parent / Guardian Phone: [Phone Number]
2. Incident Details
Incident Date: [MM/DD/YYYY]
Incident Time: [HH:MM a.m./p.m.]
Location of Incident (room, area, field, job site, street, etc.): [Location]
Type of Setting (check one):
Workplace
School / Childcare
Sports / Recreation
Home / Residential
Roadway / Vehicle / DUI-Related
Other: [Describe]
Activity at Time of Injury (be specific):
[Example: “Running during PE,” “Lifting boxes,” “Playing soccer,” “Driving,” “Walking down stairs.”]
3. Description of Incident
Provide a clear, factual description of what happened. Avoid blaming language — focus on events.
Description of Incident:
[Free-text narrative: what the injured person and others were doing, how the injury occurred, any objects/equipment involved, surfaces (wet/dry), etc.]
4. Injury Details – Body Part and Type
Body Part(s) Injured (check or describe):
Head / Scalp
Face / Eye / Nose / Mouth
Neck
Shoulder / Arm / Elbow / Wrist / Hand
Chest / Ribs
Back / Spine
Hip / Thigh / Knee / Lower Leg / Ankle / Foot
Multiple areas
Other: [Describe]
Side of Body: [Left / Right / Both / Center / Unknown]
Type of Injury (check all that apply):
Bruise / Contusion
Cut / Laceration / Scratch
Abrasion / Graze / “Road rash”
Sprain / Strain
Suspected Fracture / Dislocation
Burn (thermal / chemical / electrical)
Bite / Sting
Concussion / Head Impact (suspected)
Other: [Describe]
Visible Signs of Injury:
[Example: redness, swelling, bleeding, deformity, limited movement, discoloration.]
5. Symptoms and Pain Assessment
Injured Person’s Reported Symptoms (use their own words where possible):
[Free-text, e.g., “sharp pain when moving arm,” “dizziness,” “nausea,” “headache,” “numbness.”]
Pain Level (0–10 scale; 0 = no pain, 10 = worst pain imaginable):
Reported Pain Score: [0–10]
Other Observed Signs (check or describe):
Dizziness / unsteady gait
Confusion / disorientation
Difficulty speaking or responding
Shortness of breath
Pale / clammy skin
Loss of consciousness (duration: [Approx. time] )
Vomiting
Other: [Describe]
6. Vital Signs (If Taken)
Complete only if appropriate and within your training/role.
Time Taken: [HH:MM a.m./p.m.]
Heart Rate (pulse): [] beats per minute
Respiratory Rate: [] breaths per minute
Blood Pressure: [___ / ___ mmHg]
Temperature: [___ °F / °C]
Oxygen Saturation (if available): [___ %]
Level of Consciousness (check one):
Alert
Responds to voice
Responds to pain
Unresponsive
Notes on Vital Signs / Changes Over Time:
[Brief narrative if repeated measurements were taken.]
7. Immediate Care and Treatment Provided
Assessor / First Aider Name: [Name]
Position / Role: [Role]
First Aid Certification (if applicable): [Yes / No / Type & Expiry]
Care Provided On-Site (check all that apply):
Area cleaned with [solution, e.g., soap and water]
Bandage / dressing applied
Ice pack / cold compress applied
Pressure applied to control bleeding
Immobilization (splint, sling, brace)
Elevation of injured limb
Rest / observation in designated area
CPR / emergency life support (describe briefly)
Other: [Describe]
Was 911 / Emergency Medical Services Called? [Yes / No]
If Yes:
Time Called: [HH:MM a.m./p.m.]
Responding Agency: [Name]
Transported to Medical Facility: [Yes / No]
Facility Name: [Hospital / Clinic Name]
Did the Injured Person Leave for Medical Evaluation Independently? [Yes / No]
If Yes, where: [Clinic / urgent care / personal doctor / other]
8. Recommended Disposition
Based on observations at the time of assessment (not a medical diagnosis):
Return to normal activities with no restrictions.
Return to activity with modifications (describe):
[e.g., no running, no lifting, seated work only.]Rest and monitor symptoms; seek medical care if symptoms worsen.
See a healthcare provider as soon as practicable.
Immediate medical evaluation strongly recommended (e.g., ER, urgent care).
Other recommendation: [Describe]
Notes / Rationale for Recommendation:
[Brief explanation based on observed signs/symptoms.]
9. Notifications and Communication
Person Notified (check all that apply and add details):
Parent / Guardian
Supervisor / Manager
Coach / Activity Leader
School / Program Administrator
HR / Safety Department
Other: [Describe]
Details:
Name of Person Notified: [Name]
Role / Relationship: [Role]
Method of Notification: [In person / Phone call / Voicemail / Email / Other]
Date and Time of Notification: [MM/DD/YYYY – HH:MM a.m./p.m.]
Summary of What Was Communicated:
[Free-text summary: nature of injury, care provided, recommendations.]
10. Follow-Up and Monitoring
Planned Follow-Up Actions (check or describe):
Monitor injured person on-site for remainder of day / activity.
Request confirmation of medical evaluation from parent / employee.
Complete separate incident or accident report form.
Review equipment, environment, or procedures for safety improvements.
Other: [Describe]
Notes on Injured Person’s Condition Before Leaving Site:
[Example: “Walking independently,” “Accompanied by parent,” “Transported by EMS,” “Using crutches,” etc.]
11. Signatures
Assessor / First Aider Certification
I, [Assessor Name], certify that this Injury Assessment Form reflects my observations and understanding of the incident and care provided at the time noted.
Assessor Signature: ___________________________
Printed Name: [Assessor Full Name]
Position / Role: [Title/Role]
Date: [MM/DD/YYYY]
Injured Person / Parent / Guardian Acknowledgment (if appropriate)
I acknowledge that I have been informed about the injury described in this form and the care provided. This acknowledgment does not indicate agreement with any conclusions and is not a waiver of rights.
Name: [Injured Person / Parent / Guardian]
Signature: ___________________________
Date: [MM/DD/YYYY]
12. Additional Notes or Attachments
Additional Notes:
[Free-text area for any extra observations or comments.]
Attachments (check if included):
Photos of injury or scene
Separate incident / accident report
Doctor’s note or discharge summary
Witness statements
Other: [Describe]
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Learn more about
Injury Assessment Form Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
INJURY ASSESSMENT FORM TEMPLATE FAQ
What is an injury assessment form?
An injury assessment form is a structured document used to record the details of an injury, including when and where it occurred, the body part affected, visible signs and symptoms, pain level, and any immediate care provided. It helps create an accurate record for medical follow-up, safety reviews, insurance, or legal purposes.
Who uses an injury assessment form?
Injury assessment forms are commonly used by employers, schools, daycares, sports clubs, gyms, clinics, first-aid responders, and safety officers. They may also be used in motor vehicle accidents or DUI-related incidents when accurate documentation of injuries is needed for treatment or claims.
What information should an injury assessment form include?
A helpful injury assessment form usually includes: injured person’s details, date/time/location of incident, description of what happened, body part(s) injured, visible signs and symptoms, pain scale rating, basic vital signs (if taken), immediate first aid or treatment provided, recommendations (e.g., return to activity vs. see a doctor), and signatures of the assessor and, if needed, the injured person or guardian.
Can this injury assessment form be used for workplace, school, sports, or accident cases?
Yes. This Injury Assessment Form Template is designed to be flexible and can be used in workplaces, schools, child-care settings, sports and recreation programs, and accident situations (including DUI-related crashes). You can adapt the wording and sections to match your organization’s policies or local regulations.
How detailed should I be when completing an injury assessment?
You should focus on clear, factual observations: when and where the injury happened, what you saw, what the injured person reported, and what care was provided. Avoid guessing about diagnoses or causes — those are for medical professionals and, where relevant, legal authorities. If you’re unsure about something, it’s better to note “unknown” than to speculate.
Can AI Lawyer help me create or adapt an injury assessment form?
Yes. AI Lawyer can help structure and adapt this injury assessment form for your workplace, school, or program by suggesting layout, wording, and additional sections. You still need to follow local laws, safety rules, and medical guidance. This template and any AI-generated text are for general information and document organization only and are not medical or legal advice — clinical or legal questions should be handled by licensed professionals.
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