Workplace Injury Report Template: Care Details & Signatures

Workplace Injury Report Template

[Company / Employer Name]

[Department / Site / Facility Name]

[Street Address]

[City, State/Province, ZIP/Postal Code]

Phone: [Main Phone Number]

Email: [HR or Safety Email]

1. Incident Date, Time, and Location

Date of Incident: [MM/DD/YYYY]

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

Date and Time Reported: [MM/DD/YYYY, HH:MM a.m./p.m.]

Exact Location of Incident (building, floor, room, work area, machine, etc.):

[Example: “Warehouse – Loading Dock B,” “Production Line 2 – Conveyor Area,” “Office – Room 305,” “Construction Site – North Scaffold.”]

2. Injured Employee Information

Full Name of Injured Employee: [First, Middle, Last]

Employee ID / Payroll Number (if applicable): [Number]

Job Title / Position: [Title]

Department / Work Area: [Department]

Hire Date (approximate): [MM/YYYY or “Unknown”]

Work Status at Time of Incident (check one):

• Full-time employee

• Part-time employee

• Temporary employee

• Contractor / agency worker

• Other: [Describe]

Primary Phone: [Number]

Email Address (work or personal): [Email]

3. Person Completing This Report

Name of Person Completing Report: [Full Name]

Role / Job Title: [Title – e.g., Supervisor, Manager, Safety Officer, HR]

Department / Location: [Department]

Phone: [Direct Phone]

Email: [Work Email]

Relationship to Incident (check one):

• Direct supervisor of injured employee

• Witness to incident

• Safety / HR staff

• Other: [Describe]

4. Work Shift and Job Activity

Shift Type:

• Day

• Evening

• Night

• Rotating / other: [Describe]

Scheduled Shift for the Day of Incident:

From [Start Time] to [End Time]

Time into Shift When Incident Occurred:

[Example: “Approximately 2 hours after start of shift.”]

Task or Job Being Performed at Time of Incident (describe specific activity, not just job title):

[Example: “Lifting and stacking boxes onto pallet,” “Operating forklift,” “Cleaning production area,” “Typing at computer,” “Climbing ladder to access storage,” etc.]

5. Description of Incident (What Happened)

In your own words, provide a clear, factual description. Focus on what happened, not who is at fault.

Before the Incident:

Describe what the injured employee and others were doing immediately before the incident (e.g., “finishing a pick order,” “moving materials,” “conducting maintenance,” “walking through warehouse aisle”):

[Free-text]

Incident Narrative (step-by-step):

[Free-text narrative. Suggested points:]

• How the incident occurred (slip, trip, fall, struck by object, caught in/on/between, overexertion, repetitive motion, exposure to chemical or noise, etc.).

• Direction of movement and position of the employee at the time.

• Any involvement of machinery, tools, vehicles, or other equipment.

• What the employee came into contact with (floor, step, cart, pallet, machinery part, sharp edge, etc.).

• What happened immediately afterward (employee’s reaction, assistance provided, area secured).

6. Workplace Conditions and Hazards

Check and describe any conditions present at the time of the incident:

• Wet or slippery surface (water, oil, grease, cleaning solution) – [Describe]

• Uneven floor, steps, hole, or obstruction – [Describe]

• Cluttered or blocked walkway – [Describe]

• Poor lighting or visibility – [Describe]

• Noise, vibration, or heat – [Describe]

• Moving machinery or equipment – [Describe]

• Vehicle or mobile equipment (forklift, truck, pallet jack, etc.) – [Describe]

• Defective or damaged tool/equipment – [Describe]

• Chemical, dust, fumes, or other exposure – [Describe]

• Inadequate guarding or fall protection – [Describe]

• Weather-related condition (if outdoors) – [Describe]

• Other: [Describe]

Were any safety devices or guards removed, bypassed, or not functioning?

• No

• Yes – describe: [Description]

7. Personal Protective Equipment (PPE)

Was PPE required for this task?

• Yes

• No

• Unsure

If Yes, what PPE was required? (check all that apply):

• Safety glasses / goggles

• Face shield

• Hard hat

• Hearing protection

• Gloves (type: [Describe])

• Safety shoes / boots

• High-visibility vest

• Respirator / mask

• Fall protection (harness, lanyard, etc.)

• Other: [Describe]

Was the employee wearing required PPE at the time?

• Yes

• Partially

• No

  If partially or no, explain: [Description]

8. Injury Details and Symptoms

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

• Head / scalp

• Face / eye / nose / mouth / jaw

• Neck / cervical spine

• Shoulder / arm / elbow

• Wrist / hand / fingers

• Chest / ribs

• Upper back / mid-back

• Lower back / lumbar area

• Hip / pelvis

• Thigh / hamstring / quadriceps

• Knee

• Lower leg / shin / calf

• Ankle

• Foot / toes

• Multiple body parts

• Other: [Describe]

Type of Injury Suspected (based on employee’s report and observation):

• Bruise / contusion

• Cut / laceration

• Abrasion / scrape

• Sprain / strain

• Possible fracture or dislocation

• Burn (thermal, chemical, electrical)

• Crush or pinch injury

• Repetitive strain / overuse

• Head injury / possible concussion

• Other: [Describe]

Employee’s Reported Symptoms:

[Example: “Sharp pain in lower back when bending,” “Swelling and tenderness in right ankle,” “Numbness in fingers,” “Headache and dizziness,” etc.]

Employee’s Reported Pain Level (0–10; 0 = no pain, 10 = worst pain):

Reported Score: [0–10]

9. First Aid and Medical Treatment

Did the employee receive first aid at the scene?

• No

• Yes – provide details below.

First Aid Provider(s) (name and role):

[Name 1 – First aider, supervisor, nurse, etc.]

[Name 2 – if applicable]

Immediate Actions Taken (check and describe):

• Area made safe / work stopped

• Employee assisted to a safe area (seated / lying down)

• Ice or cold pack applied – [Where and duration]

• Wound cleaned and dressed

• Immobilization (splint, sling, brace, etc.)

• Rinsing of eyes or skin (for exposure)

• Other first aid: [Describe]

Was emergency medical service (EMS/ambulance) called?

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

• No

Was the employee transported from the workplace?

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

• Yes, by private vehicle (employee or colleague) to: [Facility]

• Yes, by supervisor/management to: [Facility]

• No, remained at workplace

• Unknown

If known, list medical facility / provider:

[Name of facility or provider, city]

10. Work Status and Lost Time

Did the injured employee stop work immediately after the incident?

• Yes

• No

Work Status for the Remainder of the Day:

• Went home / left work

• Switched to light duty

• Continued regular duties

• Other: [Describe]

Has the employee missed any full workdays due to this injury?

• Yes

• No

• Unknown at time of report

If Yes, list dates missed (if known):

From [MM/DD/YYYY] to [MM/DD/YYYY or “Ongoing”]

Has the employee been given medical restrictions (e.g., no lifting, limited hours)?

• Yes – list or attach doctor’s note: [Description]

• No

• Unknown at time of report

11. Witnesses

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

• Yes

• No

• Unknown

Witness 1:

Name: [Name]

Job Title / Role: [Role]

Department: [Department]

Phone / Email: [Contact]

Witness 2:

Name: [Name]

Job Title / Role: [Role]

Department: [Department]

Phone / Email: [Contact]

[Add additional witnesses as needed.]

Have any written witness statements been collected?

• Yes – attached

• No

• Planned / requested

12. Equipment, Materials, or Vehicles Involved

Was any equipment, tool, machinery, or vehicle involved?

• No

• Yes – describe below.

Item 1:

Type of Equipment or Vehicle: [e.g., “Forklift,” “Conveyor belt,” “Hand truck,” “Ladder,” “Power tool”]

Manufacturer / Model (if known): [Details]

Condition Observed (normal, defective, damaged, unknown): [Description]

Item 2:

Type: [Description]

Condition Observed: [Description]

Were guards, lockout/tagout, or other safety procedures required for this equipment?

• Yes – followed

• Yes – not fully followed (explain): [Description]

• No

• Unknown

13. Root Cause and Corrective Actions (Preliminary)

Based on information available now, what factors appear to have contributed to this incident? (check all that apply and describe):

• Slip, trip, or fall hazard – [Describe specific condition]

• Improper lifting or body mechanics – [Describe]

• Inadequate guarding or safety device – [Describe]

• Equipment malfunction or failure – [Describe]

• Inadequate training or instruction – [Describe]

• Failure to follow procedure or policy – [Describe]

• Housekeeping issue (clutter, debris, spills) – [Describe]

• Personal protective equipment not used or ineffective – [Describe]

• Environmental factors (weather, lighting, noise) – [Describe]

• Other: [Describe]

• Cause undetermined at this time

Immediate Corrective Actions Taken (check and describe):

• Hazard removed or area cleaned

• Warning signs or barriers placed

• Equipment tagged out of service

• Temporary procedure change implemented

• Employee re-instructed on safe work practice

• Other: [Describe]

Planned Follow-Up Actions (if known):

[Example: “Schedule maintenance inspection,” “Review training for all staff,” “Update written procedure,” “Install additional guardrails.”]

14. Attachments Checklist

Check all items attached or available with this report:

• Photos of the incident area or equipment

• Photos of visible injuries (if permitted and with consent)

• Diagram or sketch of incident location

• Witness statements

• Maintenance or inspection records

• Training records related to task/equipment

• Medical notes or work status slip (if provided)

• Safety data sheets (SDS) for any substances involved

• Other relevant documents: [Describe]

15. Additional Comments

Use this section for any other relevant information, concerns, or notes about prior similar incidents, trends, or safety suggestions.

Additional Comments:

[Free-text narrative]

16. Signatures and Review

Person Completing This Report

Name (print): _______________________________

Role / Job Title: ____________________________

Signature: __________________________________

Date Completed: [MM/DD/YYYY]

Supervisor / Manager Review

Name (print): _______________________________

Role / Job Title: ____________________________

Signature: __________________________________

Date Reviewed: [MM/DD/YYYY]

Safety / HR / Risk Management (Optional)