Injury Report

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Injury Details


  • What was the condition of the injured/ill party, when you arrived on the scene?
  • What is the actual injury?
  • Was First Aid administered? Yes No
  • If yes, who administered it?:
  • Was more than First Aid required? Yes No
  • If yes, describe
  • Was professional medical attention declined?: Yes No
  • If yes, who declined it?

  • Describe Medical attention given, if any:
  • Was injured/ill party taken to the Hospital?: Yes No
  • If yes, Name & Address of Hospital:
  • If the injured/ill party left on their own, did they say they will see a doctor? Yes No
  • If Yes, Name & Address of Physician:
  • What was the condition of the injured/ill person when they left your premises?: