Third-Party Injury Report Template

Third-Party Injury Report Template

[Business / Property / Organization Name]
[Department or Location Name, if applicable]
[Street Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Main Phone Number]
Email: [General or Risk Management Email]

1. Incident Date, Time, and Location

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

Exact Location of Incident (area, room, or zone):
[Example: “Front entrance sidewalk,” “Aisle 3 – grocery section,” “Lobby near reception desk,” “Parking lot – north side,” etc.]

Type of Location (check or describe):

• Retail store or shopping area

• Office or lobby

• Parking lot or garage

• Sidewalk / exterior walkway

• Restaurant / food service area

• Warehouse or loading area

• School or campus facility

• Event venue or public area

• Other: [Describe]

2. Injured Third Party Information

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

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

Primary Phone: [Phone Number]
Secondary Phone (optional): [Phone Number]
Email Address: [Email Address]

Preferred Contact Method: [Phone / Email / Mail / Other]

Relationship to Organization (check one):

• Customer / client

• Visitor / guest

• Vendor / contractor

• Delivery driver

• Tenant or resident

• Member / participant

• Other: [Describe]

3. Person Completing This Report

Name of Person Completing Report: [Full Name]
Role / Job Title: [Title, e.g., Manager, Supervisor, Security Officer, Front Desk, etc.]
Department / Location: [Department or area]

Phone: [Direct Phone]
Email: [Work Email]

Were you:

• An eyewitness to the incident?

• Not present at the time, but gathered information afterward?

4. Description of Incident (What Happened)

In your own words, provide a clear, factual description of the incident. Avoid opinions or assigning blame—focus on what was seen, heard, and reported.

Before the Incident:
Describe what the injured person and others were doing just before the incident. For example:
[“The customer was walking toward the checkout,” “The visitor was stepping off the curb,” “The contractor was unloading equipment,” etc.]

Incident Narrative (step-by-step):
[Free-text narrative. Suggested points:]

• What specifically happened (slip, trip, fall, struck by object, caught in door, contact with equipment, etc.).

• Direction of movement and actions of the injured person at the time.

• Any interaction with staff, other customers, vehicles, equipment, or animals.

• How the injured person landed or what they struck (floor, step, cart, shelf, door, vehicle, etc.).

Conditions Observed (check and describe if applicable):

• Wet or slippery surface (liquid, rain, spilled product, ice) – [Describe]

• Uneven surface, hole, crack, or broken step – [Describe]

• Loose mats, cords, or obstacles – [Describe]

• Poor lighting or visibility – [Describe]

• Crowded area or congestion – [Describe]

• Moving vehicles or equipment – [Describe]

• Weather-related conditions (rain, snow, ice, wind) – [Describe]

• Other factors: [Describe]

5. Injury Details and Observed Symptoms

Body Part(s) Appearing to Be Injured (check or list all that apply):

• Head / face

• Neck

• Shoulder / arm / elbow

• Wrist / hand / fingers

• Chest / ribs

• Back (upper / mid / lower)

• Hip / pelvis

• Thigh / knee

• Lower leg / ankle / foot

• Other: [Describe]

Type of Injury Suspected (based on observation or report):

• Bruise / contusion

• Cut / laceration

• Abrasion / scrape

• Sprain / strain

• Possible fracture or dislocation

• Burn (thermal, chemical, or electrical)

• Head injury / possible concussion

• Other: [Describe]

Immediate Signs and Symptoms Observed (check and describe):

• Pain or tenderness – [Location and description]

• Swelling – [Where?]

• Visible deformity or abnormal position – [Describe]

• Bleeding – [Location and severity]

• Difficulty moving or bearing weight – [Describe]

• Dizziness or unsteady walking – [Describe]

• Nausea, vomiting, or feeling faint – [Describe]

• Confusion, disorientation, or memory issues – [Describe]

• Loss of consciousness (suspected or confirmed) – [Approximate duration]

• Other: [Describe]

Injured Person’s Reported Pain Level (0–10; 0 = no pain, 10 = worst pain):
Reported Score (if provided): [0–10]

6. Immediate Response and First Aid

Was the activity/area stopped or secured after the incident?

• Yes – describe actions (e.g., “blocked off area, placed caution cones, stopped machinery”): [Description]

• No – reason: [Explain]

Person(s) Providing First Aid or Initial Response (name and role):
[Name 1 – e.g., Manager, First Aider, Security, Staff Member]
[Name 2 – if applicable]

Immediate Actions Taken (check and describe):

• Assisted injured person to safe area / seated position

• Applied ice / cold pack – [Where and for how long]

• Cleaned and bandaged minor wound

• Immobilized suspected injury (splint, sling, etc.)

• Monitored breathing, responsiveness, or symptoms

• Called emergency medical services (EMS / ambulance)

• Other actions: [Describe]

Emergency Services:
Was EMS / ambulance called?

• Yes – Time called: [HH:MM] – Time arrived: [HH:MM]

• No

Was the injured person transported from the site?

• Yes, by ambulance to: [Hospital / Clinic Name]

• Yes, by private vehicle with family / friend

• Declined transport at this time

• Unknown

If known, name of receiving facility: [Facility Name, City]

7. Witnesses and Additional Statements

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

• Yes

• No

• Unknown

Witness 1:
Name: [Name]
Relationship (customer, employee, contractor, etc.): [Relationship]
Phone / Email (if available): [Contact]

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

[Add additional witnesses as needed.]

Have any written statements been obtained from the injured person or witnesses?

• Yes – attached

• No

• Planned / requested

8. Property, Equipment, or Vehicles Involved

Was any equipment, furniture, or property involved in the incident?

• No

• Yes – describe below:

Item 1:
Type of Item (e.g., cart, shelf, door, step stool, pallet jack, vehicle): [Description]
Condition Observed (damaged, defective, normal, unknown): [Description]

Item 2:
Type of Item: [Description]
Condition Observed: [Description]

If a vehicle was involved (company or third-party):

• Vehicle Type and Description: [e.g., “Delivery van,” “Customer vehicle”]

• License Plate (if known): [Plate]

• Driver Name (if known): [Name]

9. Notifications and Follow-Up

Internal Notifications (check all that apply):

• Supervisor / manager on duty – Name: [Name] – Time notified: [HH:MM]

• Safety / risk management – Name or department: [Details]

• Security – [Details]

• Corporate office / head office – [Details]

External Notifications (if applicable):

• Liability insurer notified

• Property manager / landlord notified

• Regulatory or governmental authority notified

• Other: [Describe]

Police or Security Report:
Was law enforcement or external security involved?

• No

• Yes – Agency: [Name] – Report Number (if known): [Number]

Follow-Up Recommended:

• Review of safety procedures or training

• Inspection or repair of area/equipment

• Additional signage or barriers

• Incident review meeting with management

• Other: [Describe]

10. Attachments Checklist

Check all items attached or available with this report:

• Photos of the scene / area

• Photos of any visible injuries (if permitted by policy and consent obtained)

• Diagram or sketch of incident location

• Copies of witness statements

• Copies of any police or security reports

• Maintenance or inspection records for area/equipment

• Incident-related email or communication logs

• Other documents: [Describe]

11. Additional Comments

Use this section for any other information that may be relevant, including any unusual behavior observed, prior similar incidents, or concerns about ongoing hazards.

Additional Comments:
[Free-text narrative]

12. Signatures and Review

Person Completing This Report

Name (print): _______________________________
Role / Title: _______________________________
Signature: __________________________________
Date Completed: [MM/DD/YYYY]

Supervisor / Manager Review

Name (print): _______________________________
Role / Title: _______________________________
Signature: __________________________________
Date Reviewed: [MM/DD/YYYY]

[Optional] Risk Management / Safety Officer

Name (print): _______________________________
Role / Title: _______________________________
Signature: __________________________________
Date Reviewed: [MM/DD/YYYY]