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: ____]
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] | [____] |
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] | [____] |
Witness Name
Role
Contact
What was observed
Media available
[Name]
[Employee/Student/Customer/etc.]
[Phone/Email]
[Free-text]
[Photo/Video/CCTV/None/Unknown]
[Role]
[____]
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:
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]
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] | [____] |