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Injury Report Form

| Report Number | _________________________________ |

RanchSafety Team January 20, 2026 5 min read
In This Article

Ranch Incident Documentation Form

Use this form to document all workplace injuries, illnesses, and near-misses. Complete within 24 hours of incident. Keep records for minimum of 5 years.

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SECTION 1: BASIC INFORMATION

Report Information

FieldEntry
Report Number_________________________________
Date of Report_________________________________
Time of Report_________________________________
Report Completed By_________________________________
Title/Position_________________________________

Incident Information

FieldEntry
Date of Incident_________________________________
Time of Incident_________________________________
Exact Location_________________________________
GPS Coordinates (if remote)_________________________________
Weather Conditions_________________________________
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SECTION 2: INJURED PERSON INFORMATION

Personal Details

FieldEntry
Full Name_________________________________
Date of Birth_________________________________
Home Address_________________________________
City, State, ZIP_________________________________
Home Phone_________________________________
Cell Phone_________________________________
Email_________________________________

Employment Information

FieldEntry
Job Title_________________________________
Department/Area_________________________________
Supervisor Name_________________________________
Employment Status[ ] Full-time [ ] Part-time [ ] Seasonal [ ] Family [ ] Contractor
Date of Hire_________________________________
Years in Current Position_________________________________
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SECTION 3: INCIDENT DESCRIPTION

What Happened

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Incident Classification

  • [ ] Struck against object
  • [ ] Caught in/between
  • [ ] Fall - same level
  • [ ] Fall - different level
  • [ ] Overexertion
  • [ ] Contact with temperature extreme
  • [ ] Contact with electric current
  • [ ] Contact with harmful substance
  • [ ] Transportation incident
  • [ ] Animal-related
  • [ ] Equipment malfunction
  • [ ] Fire/explosion
  • [ ] Other: _______________________________
  • [ ] Yes - Specify: ________________________________________
  • [ ] Operating normally
  • [ ] Not operating properly
  • [ ] Safety devices bypassed
  • [ ] Being repaired/maintained
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SECTION 4: INJURY/ILLNESS DETAILS

Nature of Injury/Illness

  • [ ] Amputation
  • [ ] Animal bite/sting
  • [ ] Bruise/Contusion
  • [ ] Burn - chemical
  • [ ] Burn - thermal
  • [ ] Concussion
  • [ ] Crush injury
  • [ ] Cut/Laceration
  • [ ] Dislocation
  • [ ] Electric shock
  • [ ] Eye injury
  • [ ] Fracture
  • [ ] Hearing loss
  • [ ] Heat illness
  • [ ] Hernia
  • [ ] Internal injury
  • [ ] Poisoning
  • [ ] Puncture
  • [ ] Respiratory condition
  • [ ] Sprain/Strain
  • [ ] Other: _______________________________

Body Part(s) Affected

HEAD & FACE TORSO [ ] Head/Skull [ ] Neck [ ] Face [ ] Upper back [ ] Eye - Left [ ] Lower back [ ] Eye - Right [ ] Chest [ ] Ear - Left [ ] Abdomen [ ] Ear - Right [ ] Shoulder - Left [ ] Nose [ ] Shoulder - Right [ ] Mouth/Teeth

UPPER EXTREMITIES LOWER EXTREMITIES [ ] Arm - Left Upper [ ] Hip - Left [ ] Arm - Left Lower [ ] Hip - Right [ ] Arm - Right Upper [ ] Leg - Left Upper [ ] Arm - Right Lower [ ] Leg - Left Lower [ ] Elbow - Left [ ] Leg - Right Upper [ ] Elbow - Right [ ] Leg - Right Lower [ ] Wrist - Left [ ] Knee - Left [ ] Wrist - Right [ ] Knee - Right [ ] Hand - Left [ ] Ankle - Left [ ] Hand - Right [ ] Ankle - Right [ ] Fingers - Left [ ] Foot - Left [ ] Fingers - Right [ ] Foot - Right [ ] Toes - Left [ ] Toes - Right

[ ] Multiple body parts [ ] Internal organs [ ] Body system (circulatory, nervous, etc.) ```

Injury Severity Assessment

  • [ ] Moderate - Medical treatment required
  • [ ] Serious - Hospitalization required
  • [ ] Severe - Life-threatening
  • [ ] Fatal
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SECTION 5: TREATMENT PROVIDED

On-Site First Aid

  • [ ] Wound cleaning
  • [ ] Bandaging
  • [ ] Ice/cold pack
  • [ ] Splinting
  • [ ] CPR
  • [ ] AED used
  • [ ] Tourniquet applied
  • [ ] Eye irrigation
  • [ ] Burn treatment
  • [ ] Other: _______________________________
|-------|-------| | Name | _________________________________ | | Title/Position | _________________________________ | | Training Level | _________________________________ |

Medical Treatment

  • [ ] Yes, at scene (EMS)
  • [ ] Yes, urgent care
  • [ ] Yes, emergency room
  • [ ] Yes, doctor's office
  • [ ] Yes, hospitalized
|-------|-------| | Facility Name | _________________________________ | | Address | _________________________________ | | Phone | _________________________________ | | Treating Physician | _________________________________ | | Date of Treatment | _________________________________ |
  • [ ] Self-transported
  • [ ] Transported by supervisor/coworker
  • [ ] Ambulance
  • [ ] Helicopter
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SECTION 6: WITNESS INFORMATION

Witnesses Present

|-------|-------| | Name | _________________________________ | | Position | _________________________________ | | Phone | _________________________________ | | Witness Statement Attached | [ ] Yes [ ] No |

|-------|-------| | Name | _________________________________ | | Position | _________________________________ | | Phone | _________________________________ | | Witness Statement Attached | [ ] Yes [ ] No |

|-------|-------| | Name | _________________________________ | | Position | _________________________________ | | Phone | _________________________________ | | Witness Statement Attached | [ ] Yes [ ] No |

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SECTION 7: CONTRIBUTING FACTORS

Environmental Factors

  • [ ] Inadequate lighting
  • [ ] Wet/slippery surface
  • [ ] Uneven terrain
  • [ ] Extreme heat
  • [ ] Extreme cold
  • [ ] Dust/visibility
  • [ ] Noise
  • [ ] Confined space
  • [ ] Weather conditions
  • [ ] Other: _______________________________

Equipment Factors

  • [ ] Equipment defect/malfunction
  • [ ] Missing safety guard
  • [ ] Inadequate PPE
  • [ ] Wrong tool for job
  • [ ] Equipment not maintained
  • [ ] Improper storage
  • [ ] Other: _______________________________

Human Factors

  • [ ] Inadequate training
  • [ ] Lack of experience
  • [ ] Fatigue
  • [ ] Rushing/time pressure
  • [ ] Distraction
  • [ ] Failure to follow procedures
  • [ ] Not using available PPE
  • [ ] Working alone when shouldn't
  • [ ] Physical limitation
  • [ ] Other: _______________________________

Organizational Factors

  • [ ] Inadequate procedures
  • [ ] Inadequate supervision
  • [ ] Inadequate communication
  • [ ] Understaffed
  • [ ] Time pressure from management
  • [ ] Other: _______________________________
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SECTION 8: PERSONAL PROTECTIVE EQUIPMENT

|----------|----------|------------|-----------| | Hard hat | [ ] | [ ] | _________ | | Safety glasses | [ ] | [ ] | _________ | | Hearing protection | [ ] | [ ] | _________ | | Gloves (type: _____) | [ ] | [ ] | _________ | | Safety boots | [ ] | [ ] | _________ | | High-visibility vest | [ ] | [ ] | _________ | | Respirator | [ ] | [ ] | _________ | | Face shield | [ ] | [ ] | _________ | | Fall protection | [ ] | [ ] | _________ | | Other: _____________ | [ ] | [ ] | _________ |

________________________________________________________________

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SECTION 9: WORK STATUS

Time Lost

  • [ ] Yes
FieldEntry
Last day worked_________________________________
First day of absence_________________________________
Date returned to work_________________________________
Total days away_________________________________

Work Restrictions

  • [ ] Yes
________________________________________________________________
FieldEntry
Restriction start date_________________________________
Expected end date_________________________________
Days on restricted duty_________________________________
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SECTION 10: CORRECTIVE ACTIONS

Immediate Actions Taken

________________________________________________________________

________________________________________________________________

________________________________________________________________

Long-Term Corrective Actions

ActionResponsible PartyTarget DateCompleted
_________________________________[ ]
_________________________________[ ]
_________________________________[ ]
_________________________________[ ]

Similar Incidents

  • [ ] Yes - Describe: ________________________________________
________________________________________________________________

________________________________________________________________

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SECTION 11: REGULATORY REPORTING

OSHA Recordability

  • [ ] Yes
  • [ ] Days away from work
  • [ ] Restricted work or transfer
  • [ ] Medical treatment beyond first aid
  • [ ] Loss of consciousness
  • [ ] Significant injury diagnosed by healthcare provider

Workers' Compensation

FieldEntry
WC claim filed[ ] Yes [ ] No [ ] Pending
Claim number_________________________________
Date filed_________________________________
Insurance carrier notified[ ] Yes [ ] No
Date notified_________________________________
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SECTION 12: SIGNATURES

Injured Employee

I have reviewed this report and confirm the information is accurate to the best of my knowledge.

FieldEntry
Signature_________________________________
Date_________________________________
If employee is unable to sign, explain: _________________________________

Supervisor

FieldEntry
Signature_________________________________
Print Name_________________________________
Date_________________________________

Safety Manager/Owner

FieldEntry
Signature_________________________________
Print Name_________________________________
Date_________________________________
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ATTACHMENTS CHECKLIST

  • [ ] Witness statements
  • [ ] Photographs of incident scene
  • [ ] Photographs of injuries (with consent)
  • [ ] Medical records/reports
  • [ ] Equipment inspection records
  • [ ] Training records
  • [ ] Previous incident reports (if related)
  • [ ] Other: _______________________________
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FOLLOW-UP LOG

DateAction/UpdateBy
___________________
___________________
___________________
___________________
___________________
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Form ID: 7.5.3 Category: Health & First Aid Tools Last Updated: January 2026 Retain completed forms for minimum 5 years

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