Injury Declaration Form Template
[Your Full Name]
[Street Address]
[City, State/Province, ZIP/Postal Code]
[Phone Number]
[Email Address]
Date of Birth: [MM/DD/YYYY]
1. Case, Claim, or Reference Information
Type of Incident (check or describe):
Motor vehicle accident (including DUI-related)
Workplace injury
Slip-and-fall / premises incident
Sports / recreational injury
Assault or violence
Other: [Describe]
Date of Injury: [MM/DD/YYYY]
Time of Injury: [HH:MM a.m./p.m.]
Location of Injury (Street / Place / City / State/Province):
[Location]
Insurance Company (if applicable): [Name]
Claim Number: [Number]
Employer (if applicable): [Employer Name]
Policy / File / Reference Number (if any): [Number]
Attorney / Law Firm (if any): [Name]
2. Personal and Employment / School Information
Occupation or Student Status: [Job Title / “Student” / “Unemployed” / Other]
Employer / School Name: [Name]
Employer / School Address: [Address]
Normal Work or School Schedule (before injury):
[Example: “Mon–Fri, 9:00 a.m.–5:30 p.m.”]
3. Description of Incident
Provide a clear, factual description of how the injury occurred. Focus on what you saw, heard, and did.
On [Date] at approximately [Time] in [Location], I was:
[Describe what you were doing immediately before the incident, e.g., “driving northbound on [Street],” “walking in a grocery store aisle,” “lifting boxes at work,” “playing in a recreational soccer game.”]
Describe step by step what happened leading up to the injury, including any vehicles, equipment, substances, or conditions involved (such as wet floors, broken steps, defective tools, or other hazards).
Incident Description:
[Free-text narrative. Include:
– How the incident started.
– How you fell, were struck, twisted, or otherwise injured.
– What part(s) of your body were hit or affected.
– Any immediate sensations (pain, dizziness, numbness, etc.).]
If law enforcement, security, or an internal safety officer responded, list any report numbers or references (if known):
[Police Report No., Incident Report No., etc.]
4. Injured Body Parts and Nature of Injuries
List every body part injured in this incident and describe the injury.
Body Part(s) Injured:
[Example: “Neck – stiffness and pain,” “Lower back – sharp pain,” “Right knee – swelling and instability,” “Left wrist – suspected sprain,” “Head – headache and dizziness,” etc.]
Type(s) of Injury (check or describe):
Bruise / contusion
Cut / laceration
Sprain / strain
Suspected fracture / fracture
Concussion / head injury
Soft tissue injury (muscles, ligaments, tendons)
Burn (thermal / chemical / electrical)
Other: [Describe]
Current Symptoms (in your own words):
[Describe pain, stiffness, weakness, numbness, headaches, dizziness, sleep problems, emotional effects, etc.]
5. Medical Treatment and Providers
List all treatment you have received so far for this injury.
Initial Treatment (check and describe):
No treatment immediately after incident
First aid on site by [Name / Role]: [Description]
Emergency room visit at [Hospital Name] on [Date]
Urgent care or clinic visit at [Facility Name] on [Date]
Ongoing Treatment Providers (attach additional pages if needed):
Provider 1:
Name: [Doctor / Therapist Name]
Specialty: [e.g., Emergency Medicine, Family Medicine, Orthopedics, Physical Therapy]
Facility: [Name]
First Visit Date: [MM/DD/YYYY]
Last / Most Recent Visit Date: [MM/DD/YYYY]
Provider 2:
Name: [Name]
Specialty: [Specialty]
Facility: [Name]
First Visit Date: [Date]
Last / Most Recent Visit Date: [Date]
Treatment Received (check all that apply):
Physical examination and advice
X-rays
CT scan / MRI / other imaging
Prescription medications
Over-the-counter medications
Physical therapy
Chiropractic treatment
Counseling or psychological support
Surgery or procedure
Other: [Describe]
Have any providers given you written work or activity restrictions?
Yes – describe: [e.g., “No lifting over 10 lbs for 4 weeks,” “No driving,” “No sports activities.”]
No
Not sure
6. Time Off Work / School and Activity Limitations
Have you missed work or school because of this injury?
If Yes, specify:
Work / School Absence:
From: [MM/DD/YYYY]
To: [MM/DD/YYYY] or [“Ongoing”]
Approximate number of full days missed: [Number]
Approximate number of partial days (left early / arrived late): [Number]
Describe how the injury limits your ability to work or attend school (use your own words):
[Example: “I cannot stand for long periods,” “I cannot lift or carry items,” “Sitting for more than 30 minutes causes pain,” “Headaches make it hard to concentrate in class,” etc.]
7. Impact on Daily Life and Activities
Describe how this injury affects your daily activities outside work or school. Consider:
Personal care (bathing, dressing, grooming): [Describe]
Household tasks (cleaning, cooking, shopping): [Describe]
Family responsibilities (caring for children, elderly parents, pets): [Describe]
Driving or using public transportation: [Describe]
Hobbies, sports, or exercise: [Describe]
Sleep, mood, or mental health: [Describe]
Daily Life Impact Statement (in your own words):
[Free-text paragraph explaining how your life has changed since the injury.]
8. Prior Injuries or Conditions (If Relevant)
Have you had any previous injuries or medical conditions affecting the same body parts listed in Section 4?
If Yes, please describe briefly (including approximate dates and whether you had recovered before this incident):
[Example: “Prior low back strain in 2019; symptoms had resolved before this new accident.”]
9. Additional Information
Use this section for any other details you believe are important for your insurer, employer, attorney, or the court to understand about your injury and how it occurred.
Additional Information:
[Free-text narrative]
10. Declaration and Signature
Read carefully before signing.
I, [Your Full Name], declare that the information provided in this Injury Declaration Form is true and complete to the best of my knowledge and belief. I understand that this form may be used by insurance companies, employers, attorneys, or courts in connection with my claim or case.
I acknowledge that I am responsible for reviewing this declaration carefully and that I may wish to consult with a licensed attorney before signing and submitting it.
Signature: _______________________________
Printed Name: [Your Full Name]
Date Signed: [MM/DD/YYYY]
Place Signed (City, State/Province): [Location]
[Optional – Witness or Notary Section, if required]
Witness / Notary Name: [Name]
Title / Role: [Title / “Notary Public”]
Signature: _______________________________
Date: [MM/DD/YYYY]
Commission / ID Number (if Notary): [Number]
Commission Expiration Date (if Notary): [MM/DD/YYYY]
