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: ____]
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] | [____] |
Category | Subtype | Severity (1-5) | Basis (facts) |
[Acute injury | Illness | Exposure | Other] | [Free-text] | [1-5] | [Observable facts] |
[____] | [____] | [1-5] | [____] |
[____] | [____] | [1-5] | [____] |
Category
Subtype
Severity (1-5)
Basis (facts)
[Acute injury | Illness | Exposure | Other]
[Free-text]
[1-5]
[Observable facts]
[____]
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]
Category | Subtype | Severity (1-5) | Basis (facts) |
[Acute injury | Illness | Exposure | Other] | [Free-text] | [1-5] | [Observable facts] |
[____] | [____] | [1-5] | [____] |
[____] | [____] | [1-5] | [____] |