Free template
Injury Report Template – Illinois
Capture narrative, medical evaluation, severity classification, and evidence in an Illinois report.
Downloaded 2898 times
Download template
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]
Flash deal
Flash deal
Today
Today
No time to fill it up? Generate your custom agreement with AI Lawyer in seconds
What’s Included
Legal Research
Legal Research
Legal Research
Contract Drafting
Contract Drafting
Contract Drafting
Document Review
Document Review
Document Review
Risk Analytics
Risk Analytics
Risk Analytics
Citation Verification
Citation Verification
Citation Verification
Easy-to-understand jargon
Easy-to-understand jargon
Easy-to-understand jargon
Details
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 the benefit of using a category and severity table?
A category-subtype-severity table helps teams classify incidents consistently without relying on vague labels. By separating the type of event from a short subtype description and a severity score, the report can support trend review and consistent follow-up triage. The “basis” field is important because it captures the observable facts behind the classification, such as “restricted activity noted” or “transported for evaluation.” This approach improves internal comparability while avoiding medical diagnosis language.
Should symptoms be recorded in the injured person’s own words?
Whenever possible, record symptoms as stated to preserve meaning and avoid accidental reinterpretation. You can still document observations separately, such as swelling or limping, but keep them distinct from what was reported. If the injured person cannot provide a statement at the time, note who provided information and what was observed. Clear separation between reported symptoms and observed signs helps reviewers understand the source of each detail and reduces disputes later.
How should access to injury reports be limited within an organization?
Because injury reports contain personal information, organizations often store them in a secure location with limited access. Use an internal report ID, keep attachments linked to the same case file, and avoid informal distribution through long email chains. If the report is shared externally, consider whether contact details or sensitive information should be minimized for the purpose of the share. A consistent access approach also makes it easier to track which version is current when dated updates are added.
What if the injury develops over time rather than from one moment?
Some incidents involve symptoms that build across a shift or over days. In that situation, the narrative should capture the onset window, the tasks being performed, and when the person first noticed symptoms. If there was a particular moment that worsened the condition, record it, but do not force a single “incident moment” if it did not exist. A clear timeline of onset and task context helps internal reviewers evaluate conditions and plan follow-up without mischaracterizing what occurred.
How do you document contractor involvement without rewriting contracts?
Focus on operational facts rather than legal conclusions. Record who controlled the area, who employed the injured person, and which other entities were present. If there is a work order or service ticket, capture its identifier. These details help route follow-up communications and identify where relevant records might be found, such as maintenance logs or training documentation. Keeping this section factual reduces inconsistency and supports coordination among multiple contacts. Listing a primary on-site contact for each entity can also reduce delays when gathering logs or scheduling corrective actions.
What if there are no witnesses?
Record that no witnesses are known and then rely on the injured person’s account, responder observations, and any available evidence. Document the scene context, the reported activity, and any immediate symptoms or signs. If CCTV, access logs, or other records may exist, list the identifiers so they can be retrieved before retention windows expire. A report without witnesses can still be strong when it captures early details and preserves what can be verified.
Can the injured person provide an additional statement later?
Yes, and it is often better to keep it as a dated addendum rather than rewriting the original narrative. A later statement may clarify what the person remembers after the initial stress, or it may update symptoms and restrictions. Identify who authored the addendum, the date, and whether it was written or dictated. Linking addenda to the original report ID keeps the case file complete while showing clearly when each piece of information was provided.
What if supervisors disagree about key details?
When accounts conflict, attribute each account to the person providing it instead of merging them into a single story. Record what each person says they observed and note any evidence that might clarify the point, such as photos, logs, or camera references. The injury report’s purpose is to preserve information, not to resolve disputes immediately. Clear attribution helps later reviewers understand why details differ and what sources can be checked.
Similar templates
Other templates from
Employment Legal Templates
Money back guarantee
Free trial
Cancel anytime
AI Lawyer protects
your rights and wallet
Money back guarantee
Free trial
Cancel anytime
AI Lawyer protects
your rights and wallet
Money back guarantee
Free trial
Cancel anytime
AI Lawyer protects
your rights and wallet
Money back guarantee
Free trial
Cancel anytime