Introducing Referent – AI-native practice management software for modern law firms.
Explore Referent[Organization / Employer / School / Program Name]
[Address]
[City, State, ZIP]
Phone: [Phone Number]
Email: [Email Address]
Scene Secured: [Yes | No | N/A]
Hazard Controlled: [Stopped work | Isolated area | Shut down equipment | Traffic control | Other: ____ | N/A]
First Responder(s): [Name/Role]
On-Site Care: [Cleaned | Bandaged | Ice/cold compress | Pressure | Immobilized | Rest/observation | CPR/life support: ____ | Other: ____ | None]
EMS/911 Called: [Yes | No]
Time Called: [HH:MM a.m./p.m. / N/A]
Report/Incident ID: [Report/Incident ID]
Incident Date: [MM/DD/YYYY]
Incident Time: [HH:MM a.m./p.m.]
Location: [Address/Worksite/Route/Area]
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: ____]
Report Prepared Date: [MM/DD/YYYY]
Full Name: [First, Middle, Last]
Role: [Employee | Contractor/Vendor | Visitor/Customer | Student/Child | Athlete/Participant | Other: ____]
Work/Activity Assignment: [Job/task/activity name]
Supervisor/Point of Contact: [Name, Title]
Phone/Email: [Phone ____ | Email ____]
Before:
[What was happening before the event]
Trigger:
[Change/event that started the incident]
Contact/Mechanism:
[How the injury occurred; objects/surfaces/vehicles involved]
After:
[What happened immediately after]
Immediate Response:
[Who responded and what actions were taken]
Body Area: [General area; avoid diagnosis: ____]
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: ____]
Pain Score (0-10): [0-10]
Severity Scale: [S1 Minor/no time loss | S2 Needs evaluation | S3 Restricted activity | S4 Lost time | S5 Emergency/critical]
Severity Basis: [Observable facts supporting selected severity level]
Transported for Care: [Yes | No | Declined]
Facility/Provider: [Hospital/Clinic Name / N/A]
Visit Date: [MM/DD/YYYY / N/A]
Restrictions Provided: [Yes: ____ | No | Unknown]
Status After Incident: [Returned to duty/activity | Modified duty/activity | Sent home | Off work | Other: ____]
[Complete only if Setting Type = Roadway/Vehicle OR vehicle involved.]
Item | Details |
Vehicle 1 | [Year/Make/Model; VIN; Plate] |
Driver 1 | [Name; phone; license state/number] |
Vehicle 2 | [Year/Make/Model; VIN; Plate / N/A] |
Driver 2 | [Name; phone; insurer / N/A] |
Police/Report | [Agency; report #; responding officer; time] |
Direction/Intersection | [Free-text] |
Item | Details |
Vehicle 1 | [Year/Make/Model; VIN; Plate] |
Driver 1 | [Name; phone; license state/number] |
Vehicle 2 | [Year/Make/Model; VIN; Plate / N/A] |
Driver 2 | [Name; phone; insurer / N/A] |
Police/Report | [Agency; report #; responding officer; time] |
Direction/Intersection | [Free-text] |
Item
Details
Vehicle 1
[Year/Make/Model; VIN; Plate]
Driver 1
[Name; phone; license state/number]
Vehicle 2
[Year/Make/Model; VIN; Plate / N/A]
Driver 2
[Name; phone; insurer / N/A]
Police/Report
[Agency; report #; responding officer; time]
Direction/Intersection
[Free-text]
Photos: [Yes: IDs ____ | No]
Video/CCTV: [Yes: IDs ____ | No | Unknown]
Documents Collected: [Work order/training record/maintenance log/dispatch record/other: ____ | None]
Evidence Storage Location: [Drive/folder/case file; access owner]
Witnesses Present: [Yes | No | Unknown]
Witness 1 Name/Role: [____] Contact: [____] What Observed: [____]
Witness 2 Name/Role: [____] Contact: [____] What Observed: [____]
Witness 3 Name/Role: [____] Contact: [____] What Observed: [____]
Immediate Fixes Made: [Free-text / None]
Follow-Up Owner: [Name, Title]
Target Completion Date: [MM/DD/YYYY]
Open Items: [Free-text / None]
Notified Parties: [Supervisor/Manager | HR/Safety | Parent/Guardian | Property Owner | Fleet/Transportation | Other: ____]
Notification Date/Time: [MM/DD/YYYY - HH:MM a.m./p.m.]
Notification Summary:
Report Completed By: [Name; Role/Title; Signature; Date]
Supervisor Review: [Name; Signature; Date / N/A]
Case Owner Review: [Name; Signature; Date / N/A]
Fleet/Transportation Review: [Name; Signature; Date / N/A]
Item | Details |
Vehicle 1 | [Year/Make/Model; VIN; Plate] |
Driver 1 | [Name; phone; license state/number] |
Vehicle 2 | [Year/Make/Model; VIN; Plate / N/A] |
Driver 2 | [Name; phone; insurer / N/A] |
Police/Report | [Agency; report #; responding officer; time] |
Direction/Intersection | [Free-text] |
Each template already follows legal structure and best practices.
The agreement is automatically filled and adapted to your inputs.
Check the generated document, make edits if needed, and download a ready-to-use agreement.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Frequently asked
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.
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.
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
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
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.
Record witness statements as soon as possible, using neutral, factual language. Document each witness separately and label the statement with the witness’s name and where they were at the time. Write what the witness directly saw or heard, include where they were and the time, and avoid opinions, blame, or guesses. Keep the wording close to the witness’s own words, and have them review, date, and sign/initial the statement if your workplace process allows. If the witness is unsure about something, note it clearly as uncertainty rather than treating it as a fact.
To document the incident timeline correctly in a work injury report, list events in chronological order with specific times (or best estimates). Start with what the employee was doing before the incident, then note when it occurred, what immediate actions were taken, and when a supervisor or medical help was notified. If you don’t know an exact time, mark it as approximate and keep the wording factual.
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