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Injury Report Template – California
Capture timeline, injury details, witnesses, and response actions in one California report.
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Injury Report Template
[Organization / Employer / School / Program Name]
[Address]
[City, State, ZIP]
Phone: [Phone Number]
Email: [Email Address]
1. Incident Snapshot
Incident Date: [MM/DD/YYYY]
Incident Time: [HH:MM a.m./p.m.]
Report/Incident ID: [Report/Incident ID]
Primary Location: [Room / Area / Field / Worksite / Street / Other]
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 Type: [Workplace | School/Childcare | Sports/Recreation | Public Place/Business | Roadway/Vehicle | Home/Residential | Other: ____]
Report Prepared Date: [MM/DD/YYYY]
2. Injured Person Profile
Full Name: [First, Middle, Last]
Date of Birth: [MM/DD/YYYY]
Age: [Age]
Gender: [Gender]
Role: [Employee | Student/Child | Athlete/Participant | Visitor/Customer | Contractor/Vendor | Other: ____]
Home Address:
[Street Address]
[City, State, ZIP]
Phone Number: [Phone Number]
Email Address: [Email Address]
3. Activity at Time of Event
Task/Activity: [Free-text]
Expected/Normal for Setting: [Yes | No: ____]
Tools/Equipment/Items In Use: [Free-text / N/A]
4. Incident Narrative
Who:
[Names/roles; include third parties if any]
What:
[Free-text]
Where:
[Specific spot/route/positioning]
When:
[Sequence and timing]
Why:
[Known facts only; unknown if not established]
How:
[Mechanism; slip/trip/fall/struck/collision/sudden movement/exposure/other]
5. Injury and Symptom Summary
Injury Category: [Head/Face | Neck | Upper Extremity | Torso/Back | Lower Extremity | Multiple | Other: ____]
Injury Subtype: [Free-text]
Side of Body: [Left | Right | Both | Center | Unknown]
Injury Type: [Bruise/Contusion | Cut/Laceration | Abrasion | Sprain/Strain | Suspected Fracture/Dislocation | Burn | Bite/Sting | Head Impact (suspected) | Other: ____]
Visible Signs: [Redness/swelling/bleeding/deformity/limited movement/discoloration/none/other: ____]
Reported Symptoms:
[Free-text; use injured person words where possible]
Pain Score (0-10): [0-10]
Observed Signs: [Dizziness/unsteady | Confusion | Difficulty speaking | Shortness of breath | Pale/sweaty | Loss of consciousness: ____ | Vomiting | Other: ____]
6. Immediate Response and Disposition
Activity Stopped Immediately: [Yes | No: ____]
Responder(s) Name and Role: [List]
On-Site Care Provided: [Cleaned | Bandaged | Ice/cold compress | Pressure | Immobilization | Elevation | Rest/observation | CPR/life support: ____ | Other: ____]
EMS/911 Called: [Yes | No]
Time Called: [HH:MM a.m./p.m. / N/A]
Responding Agency: [Name / N/A]
Transported for Medical Care: [Yes | No | Declined]
Facility Name: [Hospital/Clinic Name / N/A]
Immediate Status: [Returned to normal activity | Returned with restrictions | Sent home | Transported | Other: ____]
7. Timeline Table
Time | Event/Action | Person(s) | Evidence Ref |
[HH:MM] | [Free-text] | [Name/Role] | [Photo # / Video ID / CCTV Cam / Other] |
[HH:MM] | [Free-text] | [Name/Role] | [____] |
[HH:MM] | [Free-text] | [Name/Role] | [____] |
[HH:MM] | [Free-text] | [Name/Role] | [____] |
8. Environment and Conditions
Surface/Walking Area: [Dry | Wet | Uneven | Obstructed | Slippery | Other: ____]
Lighting/Visibility: [Normal | Low | Glare | Night | Other: ____]
Weather/Temperature: [Clear/rain/wind/heat/cold/other: ____ | N/A]
Substances/Contaminants Involved: [Free-text / None]
Equipment Condition Observed: [Normal | Damaged | Missing guard | Out of place | Other: ____ | N/A]
9. Evidence Preservation
Photos Taken: [Yes: Photo IDs ____ | No]
Video/CCTV Available: [Yes: Camera IDs ____ | No | Unknown]
Physical Items Secured: [Yes: Item IDs/location ____ | No | N/A]
Access/Chain of Custody Notes: [Free-text]
Witnesses
Witnesses Present: [Yes | No | Unknown]
Name | Contact | What Observed |
[Witness 1 Name] | [Phone/Email 1] | [Brief description 1] |
[Witness 2 Name] | [Phone/Email 2] | [Brief description 2] |
[Witness 3 Name] | [Phone/Email 3] | [Brief description 3] |
10. Work/Activity Status and Classification
Medical Evaluation Sought After Scene: [Yes | No | Unknown]
Provider/Facility Type: [ER | Urgent Care | Clinic | Personal Doctor | Other: ____ | N/A]
Date of Visit: [MM/DD/YYYY / N/A]
Written Restrictions Provided: [Yes: ____ | No | Unknown]
Days Away/Restricted Duty: [Days away: ____ | Restricted: ____ | Not tracked]
Internal Classification: [First aid only | Medical treatment | Restricted activity | Lost time | Other: ____ | Not determined]
11. Notifications and Sign-Offs
Person(s) Notified: [Parent/Guardian | Supervisor/Manager | HR/Safety | Administrator | Property Owner | Other: ____]
Name and Role: [Name; relationship]
Method: [In person | Phone | Voicemail | Email | Other: ____]
Date/Time: [MM/DD/YYYY - HH:MM a.m./p.m.]
Summary of Communication:
[Free-text]
Follow-Up Owner: [Name, Title]
Target Completion Date: [MM/DD/YYYY]
Planned Follow-Up Actions: [Monitor condition | Request medical note | Inspect area/equipment | Repair/clean/modify | Training/reminder | Policy/procedure update | Other: ____ | None]
Reporting Person Name: [Full Name]
Reporting Person Title/Role: [Title/Relationship]
Reporting Person Signature: [Signature]
Reporting Person Date: [MM/DD/YYYY]
Supervisor/Manager Reviewer: [Name; Title; Signature; Date / N/A]
Safety/HR Reviewer: [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 – California
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.
California 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.
Who should complete and sign an employee injury report template in a workplace?
In most workplaces, the injured employee completes the personal statement portion of the injury report (what they were doing and what they experienced), while the supervisor or manager documents the incident facts (time, location, task, immediate response) and signs to confirm it was reported and reviewed. Witnesses may add a short statement and sometimes sign it, depending on company practice. HR or the safety team usually reviews the completed document and signs or acknowledges receipt so the workplace injury report can move through the proper procedure and be stored consistently.
What’s the difference between an injury report and an incident report?
An injury report focuses on the injury and its immediate handling—who was injured, what the injury was, what first aid or medical treatment was provided, and whether there were any work restrictions. An incident report focuses on the event that led to the injury (or could have led to one), describing what happened, the contributing conditions, and what follow-up or investigation actions are needed. Many workplaces combine both into one workplace injury report, but the key difference is that the injury report documents the outcome, while the incident report documents the incident details and suspected or contributing factors pending investigation, along with recommended prevention steps.
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