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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
Who should prepare the report if no one directly witnessed the event?
If no one saw the moment of injury, the report is typically prepared by the responder, supervisor, or staff member who gathered the initial information. The key is to clearly distinguish what was observed from what was reported. You can document the injured person’s account and any scene observations while noting the source of each detail. If information is incomplete, mark it as unknown and preserve evidence references (such as camera IDs or logs) so later reviewers can verify details without relying on memory.
Is it appropriate to include opinions about fault in the report?
In most cases, the report is more useful when it stays factual. Describe hazards, sequence, contacts or movements, and observed outcomes. If someone offers an opinion, it can be captured as a quoted statement attributed to that person, but avoid presenting it as a conclusion. A neutral report is easier to review consistently across incidents and reduces the risk that the document becomes argumentative. Follow-up reviewers can assess cause later using evidence, witness statements, and other records.
What should be recorded when multiple employers or contractors are present?
Document the operational chain: the site controller, the injured person’s employer, and other entities working nearby. This helps route communications and identify where records may be located, such as training, maintenance, or work orders. If equipment was involved, note who owned or controlled it at the time, without making legal conclusions. These fields reduce confusion when follow-up involves different supervisors, vendors, or property representatives and helps ensure corrective actions are assigned to the right contacts.
How should witness information be captured without pressuring witnesses?
Use simple, non-leading prompts: who the witness is, how to contact them, and what they say they observed. Keep summaries short and avoid rewriting a witness statement into conclusions the witness did not make. If a witness arrived after the incident but saw conditions or heard relevant sounds, record that distinction. The witness matrix structure helps keep statements comparable across witnesses and reduces the chance of duplicated or inconsistent narratives.
What if the injured person declines medical evaluation?
Record the refusal as a factual outcome and document what assistance was offered. Capture any symptoms reported at the time and any observable condition, such as swelling, limping, or disorientation. Declining care does not mean the incident was minor, so assign a follow-up owner to check whether symptoms changed or restrictions were later provided. If the person later seeks care, add a dated update with the visit information and the source of the update rather than rewriting the original report.
How do claim or insurance details fit into the report?
Claim fields help with routing and tracking, especially if a third-party administrator or insurer is involved. If a claim number has not been assigned, leave it as “not assigned” rather than guessing. Keep claim information separate from the incident narrative so the factual account remains clean. Listing an internal case owner and a claims contact reduces delays, prevents duplicate reporting, and makes it easier to locate attachments and updates linked to the same report.
What is a practical retention approach for injury reports?
Retention practices vary by organization, but a good approach is to store reports securely with limited access and consistent naming by date and report ID. Keep attachments and later updates linked to the same report so the file stays complete. Because delayed symptoms and follow-up questions can arise well after the incident, avoid deleting reports quickly. If your organization has an internal retention schedule, apply it consistently and ensure the record remains readable and retrievable over time.
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