Workers Compensation Injury Triage Worksheet

Triage worksheet for reported workplace injuries to assess severity, immediate medical needs, compensability indicators, and claim setup readiness within 24 to 48 hours.

Report Overview

• Date reported
• Time reported
• Reported by
• Reporter role
• Date of injury
• Time of injury
• Location of incident
• Submit anonymously if permitted by policy

Injured Worker

• Worker name
• Employee ID
• Department
• Job title
• Employment status

Injury Triage

• Type of injury or event
• Body part affected
• Initial severity level
• Was the worker able to continue working after the incident?
• Is lost time from work expected?
• Is immediate medical attention needed?
• Triage notes
  Brief factual notes only. Include observable symptoms, visible injury, and immediate actions taken.

Compensability Questions

• Did the injury occur while performing work duties?
• Did it occur on company premises or at an assigned worksite?
• Was equipment, machinery, or a vehicle involved?
• Was required PPE worn?
• Were there witnesses?
• Witness names
• Was there a prior reported condition or recurring issue?

Immediate Response

• Was first aid provided?
• First aid details
• Was the worker sent for medical evaluation?
• Medical provider type
• Temporary work restrictions

Follow-up and Submission

• Assigned to
• Follow-up due date
• Is this ready for claim setup?
• Additional notes