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Injury Report Template – Washington
Document evidence, witness media IDs, symptoms, care, and head-impact screening in Washington.
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Injury Report Template
[Organization / Employer / School / Program Name]
[Address]
[City, State, ZIP]
Phone: [Phone Number]
Email: [Email Address]
1. Evidence and Documentation Capture
Initial Photos Taken: [Yes: IDs ____ | No]
Video/CCTV Source: [Camera IDs ____ | Bodycam ____ | Phone video ____ | None | Unknown]
Access Log / File Path: [Drive/folder/path; access owner]
Preservation Notes: [Free-text]
Witnesses
Witnesses Present: [Yes | No | Unknown]
Witness | Best Contact | Key Observation | Media/Link ID(s) |
[Name 1] | [Phone/Email 1] | [What seen/heard 1] | [Photo/Video ID(s) 1 / N/A] |
[Name 2] | [Phone/Email 2] | [What seen/heard 2] | [Photo/Video ID(s) 2 / N/A] |
[Name 3] | [Phone/Email 3] | [What seen/heard 3] | [Photo/Video ID(s) 3 / N/A] |
2. Incident Basics
Report/Incident ID: [Report/Incident ID]
Incident Date: [MM/DD/YYYY]
Incident Time: [HH:MM a.m./p.m.]
Location: [Room/Area/Worksite/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: ____]
3. Injured Person Information
Full Name: [First, Middle, Last]
Role: [Employee | Student/Child | Athlete/Participant | Visitor/Customer | Contractor/Vendor | Other: ____]
Date of Birth: [MM/DD/YYYY]
Phone/Email: [Phone ____ | Email ____]
Address (optional):
[Street Address]
[City, State, ZIP]
Best Time to Reach: [Days/Hours]
4. Event Narrative
Scene:
[What the area looked like; key objects/conditions]
Event:
[What occurred and who did what]
Mechanism:
[How the injury occurred; contact/exposure details]
Response:
[Actions taken immediately; who responded]
Follow-Up:
[Next steps known at time of report]
5. Symptoms and Functional Impact
Reported Symptoms: [Free-text]
Pain Score (0-10): [0-10]
Functional Limits: [Walking/standing/gripping/bending/vision/breathing/concentration/other: ____]
Observable Signs: [Bleeding | Swelling | Limping | Confusion | Shortness of breath | None observed | Other: ____]
6. Immediate Care and Medical Evaluation
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]
Restrictions: [Free-text / None / Unknown]
7. Evidence Checklist
Item Type | ID/Reference | Location/Source | Retention/Notes |
Photo | [Photo #/Link] | [Device/Folder] | [____] |
Video/CCTV | [Camera ID/Clip ID] | [System/Owner] | [____] |
Document | [Log/Record ID] | [Folder/Owner] | [____] |
Physical Item | [Item ID] | [Storage location] | [____] |
8. Head Impact Screening [Use only if head/neck involved OR sports/recreation setting]
Section Used: [Yes | No | N/A]
Head Impact Reported or Observed: [Yes | No | Unknown]
Observed Signs: [Loss of consciousness | Vomiting | Confusion | Severe headache | Neck pain | Other: ____ | None observed]
Removed From Activity: [Yes | No | N/A]
Return-to-Activity Plan: [Free-text / N/A]
9. Notifications and Signatures
Notified Parties: [Supervisor/Manager | HR/Safety | Parent/Guardian | Program Director | Other: ____]
Date/Time Notified: [MM/DD/YYYY - HH:MM a.m./p.m.]
Communication Summary:
[Free-text]
Case Owner: [Name; Title/Role; Signature; Date]
Supervisor Review: [Name; Signature; Date / N/A]
Safety Lead 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 – Washington
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.
Washington Injury Report Template FAQ
What counts as evidence for an injury report?
Evidence includes anything that helps later reviewers understand the scene and the sequence, such as photos, CCTV clip references, equipment identifiers, maintenance or cleaning logs, and responder notes. The key is that items are labeled so they can be retrieved, especially when systems overwrite data after a retention period. Evidence does not have to prove a conclusion; it preserves context and supports follow-up, including corrective actions and communication with stakeholders. If you are unsure whether an item is relevant, record its identifier and storage location.
How should photos and CCTV references be labeled in the report?
Use consistent identifiers that match where files are stored. A simple approach is “Photo 1-4” plus a folder path, or “CCTV Cam 08 clip ID 2025-12-13-1430” plus the system owner. If your organization uses a case ID, include it in the file name or folder. In the report, capture both the ID and the source, so someone else can retrieve the file without relying on the original reporter. Good labeling reduces delays when follow-up occurs days or weeks later.
When should a head-impact screening section be used?
Use it when a head impact is reported or observed, when the person shows concerning signs like confusion or vomiting, or when the setting makes head contact plausible, such as sports, falls, or vehicle impacts. The purpose is to record observed signs and actions taken, not to diagnose. Noting whether the person was removed from activity and what follow-up plan existed helps keep the report complete. If no head impact is suspected, mark the section as not applicable and proceed with the standard symptom fields.
How do you document remote locations or access constraints?
Remote incidents benefit from precise location information. Capture GPS coordinates when available, the nearest landmark or access point, and any entry restrictions such as gate codes or limited cell coverage. Also note the closest medical facility and approximate travel time if known. These details help explain response timing and help future responders reach the same spot. Even on large campuses, access notes can matter, so document building entrances, floor levels, or route details when relevant.
What if the person returns to work but later reports symptoms?
Late symptom reporting is common with strains, head impacts, and some exposures. The report should distinguish the incident time from the time symptoms were reported. If the report is already filed, add a dated update that records the new symptoms and the source of the information. Document any changes to restrictions or work status as they are communicated. This keeps the record accurate without implying that the initial assessment was wrong; it simply reflects that additional information became available later.
Can the report be completed the same day if some information is unknown?
Yes, and it is often better to capture a timely baseline record than to wait. If key items are unknown, mark them as unknown and assign a follow-up owner. You can add attachments or updates later when witness contacts, medical visit details, or evidence identifiers are obtained. Keeping updates dated maintains transparency about what was known at each stage. The evidence checklist is especially helpful for tracking what still needs to be collected or preserved.
How does AI Lawyer help tailor this form to different programs?
AI Lawyer can adjust section order and modules so the same core injury report works for a workplace, a school, or a recreation program without losing consistency. For example, you can expand evidence tracking where CCTV is common, add head-impact prompts for sports settings, or change the reviewer chain to match your internal routing. That flexibility helps teams capture the same core facts while fitting real-world workflows. After tailoring, keep completed reports factual, and add dated updates instead of rewriting earlier entries.
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