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Run: Workers Compensation Injury Triage Worksheet

Use this Workers Compensation Injury Triage Worksheet to capture the facts, severity, and immediate response for a reported workplace injury before claim set...

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Report Overview

Date reported (required)

Time reported (required)

Reported by (required)

Reporter role (required)

Date of injury (required)

Time of injury

Location of incident (required)

Submit anonymously if permitted by policy

Yes No N/A

Injured Worker

Worker name (required)

Employee ID

Department

Job title

Employment status

Injury Triage

Type of injury or event (required)

Body part affected (required)

Initial severity level (required)

Was the worker able to continue working after the incident? (required)

Is lost time from work expected?

Is immediate medical attention needed? (required)

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? (required)

Did it occur on company premises or at an assigned worksite? (required)

Was equipment, machinery, or a vehicle involved? (required)

Was required PPE worn?

Were there witnesses? (required)

Witness names

Was there a prior reported condition or recurring issue?

Immediate Response

Was first aid provided? (required)

First aid details

Was the worker sent for medical evaluation? (required)

Medical provider type

Temporary work restrictions

Follow-up and Submission

Assigned to

Follow-up due date

Is this ready for claim setup? (required)

Additional notes

Get your results

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Email (required)

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