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Injury Report Template – Illinois
Capture narrative, medical evaluation, severity classification, and evidence in an Illinois report.
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Injury Report Template
[Organization / Employer / School / Program Name]
[Address]
[City, State, ZIP]
Phone: [Phone Number]
Email: [Email Address]
1. Report Administration
Report/Incident ID: [Report/Incident ID]
Prepared Date: [MM/DD/YYYY]
Prepared By: [Name, Title/Role]
Incident Type: [Injury | Illness | Exposure | Near-miss with symptoms | Other: ____]
2. Injured Person Information
Full Name: [First, Middle, Last]
Role: [Employee | Student/Child | Athlete/Participant | Visitor/Customer | Contractor/Vendor | Other: ____]
Date of Birth: [MM/DD/YYYY]
Phone/Email: [Phone ____ | Email ____]
Address:
[Street Address]
[City, State, ZIP]
3. Incident Date, Time, and Location
Incident Date: [MM/DD/YYYY]
Incident Time: [HH:MM a.m./p.m.]
Location: [Room/Area/Worksite/Street]
Remote/Outdoor or hard-to-access location? [Yes/No]
[If Yes, complete the fields below.]
GPS Coordinates: [GPS Coordinates]
Nearest Cross-Street/Landmark: [Nearest Cross-Street/Landmark]
Access Notes: [Gate code/entry point/boat access/other]
Closest Facility (distance/time): [Closest facility name + distance/time]
Setting: [Workplace | School/Childcare | Sports/Recreation | Public Place/Business | Roadway/Vehicle | Home/Residential | Other: ____]
4. Event Narrative
Task:
[What the person was doing]
Deviation:
[What changed or went wrong]
Source:
[Object/substance/surface/equipment/other]
Contact:
[How the person was struck/twisted/exposed/other]
Outcome:
[Immediate result and observed effects]
5. Medical Evaluation and Restrictions
Observed Signs (check or describe): [Swelling | Bleeding | Bruising | Redness | Deformity | Limited motion | Dizziness | N/A | Other: ____]
Symptoms (1–2 sentences): [Free-text]
Pain Score (0–10): [0–10 / Unknown]
Medical Visit After Scene: [Yes | No | Unknown]
Facility/Provider Type: [ER | Urgent Care | Clinic | Personal Doctor | Other: ____ | N/A]
Visit Date: [MM/DD/YYYY / N/A]
Restrictions/Notes: [Free-text / None / Unknown]
Status After Incident: [Returned to normal activity | Modified activity | Sent home | Transported | Other: ____]
6. Witness Summary
Witnesses Present: [Yes | No | Unknown]
Witness List and Brief Summaries:
Witness 1: [Name; role; phone/email; what seen/heard]
Witness 2: [Name; role; phone/email; what seen/heard]
Witness 3: [Name; role; phone/email; what seen/heard]
7. Classification Table (Category/Subtype/Severity/Basis)
Category | Subtype | Severity (1-5) | Basis (facts) |
[Acute injury | Illness | Exposure | Other] | [Free-text] | [1-5] | [Observable facts] |
[____] | [____] | [1-5] | [____] |
[____] | [____] | [1-5] | [____] |
8. Multi-Employer / Contractor Chain
Host/Site Controller: [Name]
Employer of Injured Person: [Name]
Other Entities Present: [GC/subs/vendor/tenant/other: ____ | None]
Work Order/Service Ticket: [ID / N/A]
Equipment Ownership: [Host | Contractor | Vendor | Injured person employer | Other: ____ | N/A]
9. Evidence Checklist
Media IDs: [Photos ____ | Video/CCTV ____ | Audio ____ | None]
Documents: [Training record | Maintenance log | Cleaning log | Dispatch record | Other: ____ | None]
Physical Items: [Secured item IDs/location ____ | None | N/A]
Storage Location: [Drive/folder/case file; access owner]
10. Signatures and Review Chain
Reporting Person: [Name; Signature; Date]
HR Review: [Name; Signature; Date / N/A]
Safety Committee/Officer Review: [Name; Signature; Date / N/A]
Injured Person/Guardian Acknowledgment: [Name; Signature/Declined; Date / N/A]
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Learn more about
Injury Report Template – Illinois
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.
Illinois Injury Report Template FAQ
What is an Injury Report?
An injury report is a document used to record the facts of a workplace injury or incident in a clear, consistent way. It captures what happened, when and where it occurred, who was involved, and what immediate actions were taken, so the details aren’t lost or based on memory. The goal is to support timely follow-up, review, and prevention steps. Many workplaces use an injury report template to keep this information organized in the same format each time.
When should you complete an injury report?
You should complete an injury report any time an injury happens during work or a work-related activity — even if it seems minor at first. This is especially important if first aid is provided, medical attention is needed, a supervisor must be informed, or the incident could result in time off or work restrictions. Many workplaces also document near-misses when the situation could realistically have caused an injury. A simple rule: if it needs review, follow-up, or prevention steps, it should be reported.
What should an injury report include?
A good injury report should capture the essential facts in a neutral, easy-to-review way, so nothing important is missed during follow-up.
Date and time of the incident
Exact location (site/area/room)
People involved (injured person, supervisor, witnesses)
What happened (clear, step-by-step description of events)
Injury details (body part affected, symptoms observed or reported, visible signs)
Immediate actions taken (first aid provided, medical care sought, emergency response)
Contributing conditions (environment, equipment/tools, PPE, procedures, training)
Signatures and dates (to confirm review and accuracy)
Attachments (photos, diagrams, witness notes), if applicable
What should you do after completing an injury report?
First, submit the completed injury report to the correct person or department (manager, HR, or safety) following your workplace process. Next, ensure the injured person gets appropriate care and that any work restrictions or return-to-work steps are documented. Then review the incident to identify contributing factors and agree on corrective actions (fix hazards, update procedures, repair equipment, or retrain staff). Finally, store the report according to policy and follow up to confirm actions were completed and the risk is reduced.
What supporting evidence should be attached to an injury report?
Attach only evidence that helps clarify what happened and supports follow-up. Common examples include photos of the area/equipment, a simple sketch or layout of the location, witness notes or signed statements, and any relevant maintenance/training records if they relate directly to the incident. If medical care was involved, note the type of care and where it was received, and attach documentation only if your policy allows and it’s legally appropriate.
What details should be avoided in an injury report?
Avoid opinions, blame, and assumptions about causes (for example “careless” or “the machine definitely failed”)—stick to observable fact. Also avoid unnecessary personal or sensitive information, especially detailed medical history, diagnoses, or other private data that isn’t required for workplace documentation. Don’t include speculation, rumors, or unrelated performance comments; keep the report focused on the incident and immediate actions taken.
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