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]
