Product-Related Injury Report Template

Product-Related Injury Report Template

[Company / Organization / Personal Records]
[Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Email: [Email Address]

1. Reporting Party Information

Full Name of Person Completing This Report: [First, Middle, Last]
Relationship to Injured Person:
[Self / Parent / Guardian / Employer / Supervisor / Other]

Phone Number: [Primary Phone]
Email Address: [Email Address]

Mailing Address:
[Street Address]
[City, State/Province, ZIP/Postal Code]

2. Injured Person Information

Full Name of Injured Person: [First, Middle, Last]
Date of Birth: [MM/DD/YYYY]
Age at Time of Incident: [Age]
Gender: [Gender]

Home Address (if different from above):
[Street Address]
[City, State/Province, ZIP/Postal Code]

Phone Number: [Phone Number]
Email Address: [Email Address]

3. Product Information

Product Name: [As shown on product or packaging]
Brand / Manufacturer: [Brand / Company Name]
Model / Version / Style Number: [Model ID or “Unknown”]
Serial or Batch/Lot Number (if available): [Number or “Unknown”]

Product Category (check or describe):

• Household appliance (e.g., heater, blender, fan)

• Power tool or equipment

• Children’s toy or product

• Furniture or fixture

• Electronics / battery-powered device

• Vehicle part or accessory

• Medical or health-related product (non-prescription)

• Cosmetic / personal care product

• Workplace machinery or equipment

• Other: [Describe]

Where was the product obtained?

• Retailer / Store Name (online or physical): [Name]

• Purchase Date (approximate if necessary): [MM/DD/YYYY]

• Order or Receipt Number (if available): [Number]

4. Product Use at Time of Incident

Who was using the product when the incident occurred?

• Injured person

• Another person (name/relationship): [Name, Relationship]

Describe how the product was being used at the time:
[Free-text – e.g., “Blender was being used to blend soft food,” “Space heater was plugged in and turned on low in bedroom,” “Child was riding the toy as instructed,” etc.]

Was the product being used:

• According to instructions and normal intended use

• Slightly differently from instructions (explain): [Description]

• In a way that might be considered unintended (explain): [Description]

Were any modifications, repairs, or customizations made to the product before the incident?

• No

• Yes – describe briefly: [Description]

5. Incident Date, Time, and Location

Date of Incident: [MM/DD/YYYY]
Approximate Time: [HH:MM a.m./p.m.]

Location Where Incident Occurred:
[Home / Workplace / Public place / School / Other]

Address or Description of Location:
[Street, room/area (e.g., “kitchen,” “garage,” “factory line 3”), city, state/province]

6. Description of Incident (What Happened)

Provide a clear, factual description of the incident. Avoid speculation; describe what you saw, heard, and experienced.

Incident Narrative:

On [Date] at approximately [Time], the product was being used as described above when:

[Step-by-step description. Suggested structure:]

1. Describe what you noticed just before the incident (smell, sound, malfunction, damage, warning lights, discomfort, etc.).

2. Describe exactly what the product did or failed to do (for example: overheated, broke, leaked, caught fire, exploded, failed to stop, sharp edge exposed, part detached).

3. Describe how the product’s behavior led to the injury (for example: hot liquid spilled on skin, blade contacted hand, chair collapsed, electric shock, chemical contact with eyes or skin, fall caused by product failure).

4. Describe what happened immediately afterward (people’s reactions, emergency actions, product condition).

7. Injuries and Symptoms

Describe all injuries believed to be related to this product incident.

Body Part(s) Injured:
[Example: right hand, left eye, face, chest, lower back, right foot, etc.]

Type(s) of Injury (check all that apply and describe):

• Cut / laceration – [Description]

• Burn (thermal / electrical / chemical) – [Description]

• Bruise / contusion – [Description]

• Abrasion / scrape – [Description]

• Puncture wound – [Description]

• Fracture / suspected fracture – [Description]

• Eye injury (irritation, foreign object, chemical exposure) – [Description]

• Allergic reaction / rash – [Description]

• Internal or unknown injury (pain, difficulty breathing, etc.) – [Description]

• Other: [Describe]

Immediate Symptoms After Incident:
[Example: pain, redness, swelling, difficulty moving limb, breathing problems, dizziness, headache, nausea, vision changes.]

Current Symptoms (at time of completing this report):
[Free-text description – what still hurts or is affected.]

8. Medical Treatment

Was medical treatment sought for this injury?

• No, self-care only

• Yes, first aid only (bandages, rinsing, etc.)

• Yes, professional medical care

If professional medical care was received, complete the following:

Initial Treatment Location (check all that apply):

• Emergency room / hospital

• Urgent care clinic

• Primary care doctor

• Specialist (e.g., orthopedist, ophthalmologist, dermatologist)

• Occupational health or company clinic

• Other: [Describe]

Facility / Provider Name(s): [Names and locations]
Date(s) of Treatment: [MM/DD/YYYY – list or range]

Treatment Provided (brief summary):
[For example: wound cleaning and stitches, burn care, imaging (X-ray/CT/MRI), medications, eye irrigation, splint or cast, surgery, follow-up visits, physical therapy.]

Are additional medical visits or follow-up care expected?

• Yes – describe (future appointments, therapy, surgery, etc.): [Description]

• No

• Unknown

9. Product Condition After the Incident

Describe the current condition of the product:

• Still intact but appears damaged (explain): [Description]

• Broken or in multiple pieces (describe which parts): [Description]

• Melted, burned, or scorched (describe): [Description]

• Leaking or spilling contents (describe): [Description]

• No obvious damage, but malfunction occurred (describe): [Description]

Where is the product now?

• In my possession, stored at: [Location]

• With my employer or organization

• Returned to retailer

• Returned or shipped to manufacturer

• Discarded (describe how and when): [Description]

Have any photos or videos been taken of:

• The product after the incident? [Yes / No]

• The area where the incident occurred? [Yes / No]

• The injuries? [Yes / No]

If Yes, note where they are stored or who has copies:
[Description]

10. Product Documentation and Prior Issues

Do you have any of the following (check all that apply):

• Original purchase receipt or invoice

• Warranty card or registration

• Instruction manual

• Product packaging or labels

• Emails or messages with retailer or manufacturer

Have you had any prior problems, malfunctions, or near-miss incidents with this product?

• No

• Yes – describe: [Description, including dates and what happened]

Are you aware of any recalls, safety alerts, or online complaints about this product or model?

• No

• Yes – describe briefly (if known): [Description or links/reference]

11. Witnesses and Additional Parties

Were there any witnesses to the incident or its immediate aftermath?

• No

• Yes – list below

Witness 1:
Name: [Name]
Relationship or Role (e.g., coworker, family member, customer): [Role]
Phone / Email: [Contact]

Witness 2:
Name: [Name]
Relationship or Role: [Role]
Phone / Email: [Contact]

[Add additional witnesses as needed.]

If the incident occurred at work or in a business, was it reported to a supervisor, safety officer, or manager?

• Yes – Name and Title: [Name, Title] – Date Reported: [MM/DD/YYYY]

• No

• Not applicable

12. Insurance, Claims, and Notifications (If Applicable)

Have you notified any of the following about this incident? (check all that apply):

• Health insurance company

• Homeowners or renters insurance

• Product liability or general liability insurer

• Employer’s workers’ compensation insurer

• Manufacturer or retailer of the product

• Government or safety agency

• Attorney or law firm

Provide details for any that apply (names, claim numbers, dates of contact):
[Free-text]

13. Attachments Checklist

Check all documents, images, or records attached to or available with this report:

• Photos or videos of the product

• Photos or videos of the injury or scene

• Purchase receipt or proof of purchase

• Instruction manual / safety warnings

• Warranty or registration information

• Medical records or visit summaries

• Medical bills or expense records

• Correspondence with manufacturer, retailer, or insurer

• Incident or safety reports from employer or facility

• Other relevant documents: [Describe]

14. Additional Information

Use this section to include any other details that may help explain what happened or why you believe the product caused or contributed to the injury.

Additional Information:
[Free-text narrative]

15. Declaration and Signature

I, [Full Name], declare that the information provided in this Product-Related Injury Report is true and accurate to the best of my knowledge and recollection. I understand that this report may be used by manufacturers, retailers, employers, insurers, safety agencies, or legal representatives to evaluate the incident and potential claims.

I understand that this form itself does not determine legal responsibility, warranty coverage, or compensation, and I may wish to consult a licensed attorney or other professional about my rights and options.

Signature: _______________________________
Printed Name: [Full Name]
Date Signed: [MM/DD/YYYY]

Place Signed (City, State/Province): [Location]

16. For Internal / Office Use Only (Optional)

Report Received By: [Name / Title]
Organization / Department: [Name]

Date Received: [MM/DD/YYYY]

Internal Reference / Case Number: [Number]

Notes / Follow-Up Actions:
[Brief internal notes or action items, if used by an organization.]