Third-Party Injury Report Template: Details & Liability

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]

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]

Customer / client

Visitor / guest

Vendor / contractor

Delivery driver

Tenant or resident

Member / participant

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?

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.).

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]

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]

Head / face

Neck

Shoulder / arm / elbow

Wrist / hand / fingers

Chest / ribs

Back (upper / mid / lower)

Hip / pelvis

Thigh / knee

Lower leg / ankle / foot

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]

Bruise / contusion

Cut / laceration

Abrasion / scrape

Sprain / strain

Possible fracture or dislocation

Burn (thermal, chemical, or electrical)

Head injury / possible concussion

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]

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]

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]

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]

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

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

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

Yes

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

Yes – attached

Planned / requested

8. Property, Equipment, or Vehicles Involved

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

• No

• Yes – describe below:

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]

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]

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]

Liability insurer notified

Property manager / landlord notified

Regulatory or governmental authority notified

Police or Security Report:

Was law enforcement or external security involved?

• No

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

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]

Review of safety procedures or training

Inspection or repair of area/equipment

Additional signage or barriers

Incident review meeting with management

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]

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