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Injury Report Template – New York
Record hazards, symptoms, witnesses, and claim details with this New York report.
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Injury Report Template
[Organization / Employer / School / Program Name]
[Address]
[City, State, ZIP]
Phone: [Phone Number]
Email: [Email Address]
1. Injured Person and Role
Full Name: [First, Middle, Last]
Role: [Employee | Student/Child | Athlete/Participant | Visitor/Customer | Contractor/Vendor | Other: ____]
Date of Birth: [MM/DD/YYYY]
Preferred Contact: [Phone ____ | Email ____ | Other: ____]
Address:
[Street Address]
[City, State, ZIP]
2. Where and When
Report/Incident ID: [Report/Incident ID]
Incident Date: [MM/DD/YYYY]
Incident Time: [HH:MM a.m./p.m.]
Exact Location: [Room/Area/Workstation/Entrance/Field/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: ____]
Weather/Visibility: [Free-text / N/A]
3. Event Description
Hazard Present:
[Condition/agent/source]
Control/Barrier in Place:
[Guard/training/signage/procedure/other; N/A if none]
Control Failure or Gap:
[Free-text; unknown if not established]
Exposure/Event:
[How the person contacted the hazard]
Injury Outcome:
[Immediate effect observed/reported]
4. Impact and Symptoms
Primary Complaint: [Free-text]
Functional Limits Noted: [Walking/standing/gripping/bending/vision/breathing/concentration/other: ____]
Pain Score (0-10): [0-10]
Observable Signs: [Swelling | Bleeding | Limping | Disorientation | Shortness of breath | None observed | Other: ____]
Body Area: [General area: ____]
5. Immediate Response and Medical Follow-Up
Responder(s): [Names/roles]
On-Site Care: [Cleaned | Bandaged | Ice/cold compress | Pressure | Immobilized | Rest/observation | Other: ____ | None]
EMS/911 Called: [Yes | No]
Transported: [Yes | No | Declined]
Medical Visit After Scene: [Yes | No | Unknown]
Facility/Provider: [Name / N/A]
Visit Date: [MM/DD/YYYY / N/A]
Restrictions: [Free-text / None / Unknown]
6. Witness Matrix
Witnesses Present: [Yes | No | Unknown]
Witness Name | Role | Contact | What was observed | Media available |
[Name] | [Employee/Student/Customer/etc.] | [Phone/Email] | [Free-text] | [Photo/Video/CCTV/None/Unknown] |
[Name] | [Role] | [Phone/Email] | [Free-text] | [____] |
[Name] | [Role] | [Phone/Email] | [Free-text] | [____] |
7. Claim / Insurance Intake
Insurer/TPA: [Name / N/A]
Policy Number: [____ / N/A]
Claim Number: [____ / Not assigned]
Adjuster/Case Contact: [Name, Phone, Email / N/A]
Internal Case Owner: [Name, Title, Contact]
8. Multi-Employer / Contractor Chain
Site/Location Controller: [Owner/Lessee/Host entity]
General Contractor: [Name / N/A]
Employer of Injured Person: [Name]
Other On-Site Entities: [List / None]
Tool/Equipment Ownership: [Host | Injured person employer | Vendor | Other: ____ | N/A]
9. Notifications and Signatures
Notified Parties: [Supervisor/Manager | Administrator | HR/Risk | Parent/Guardian | Property Owner | Other: ____]
Notification Method and Time: [Method ____ | MM/DD/YYYY - HH:MM a.m./p.m.]
Notification Summary:
[Free-text]
Prepared By: [Name; Title/Role; Signature; Date]
Department Head/Administrator Review: [Name; Signature; Date / N/A]
Risk/Claims 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 – New York
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.
New York 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 are the most common mistakes people make when writing a workplace injury report?
The most common issue is writing an injury report in a vague or subjective way (opinions, blame, or assumptions) instead of a clear, factual timeline of what happened. Another frequent mistake is leaving out key context—exact location, who was notified, witness details, and what immediate first aid/medical action was taken—so the workplace injury report can’t be reviewed consistently. People also forget to attach or reference supporting evidence (photos/notes), which makes follow-up and investigation harder.
How long should a workplace keep completed injury reports (record retention best practice)?
In the U.S., a common baseline is to align retention with OSHA recordkeeping rules: when required, employers must keep OSHA injury and illness records (Forms 300, 300A, and 301) for five years following the end of the calendar year they cover. For other injury reports your company uses (internal reports, investigation notes, witness statements), many workplaces keep them at least as long as the related OSHA record and longer if there’s a claim, dispute, or ongoing restrictions—especially for lost time cases.
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