Slip and Fall Incident Report Form – Fill Out and Use This PDF

Slip Fall Incident Report Sample PDF Details

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1. Fill in Basic Incident Details

2. Describe the Incident

3. Document Environmental Conditions

4. Report Timing and Witnesses

5. Provide Claimant Information

6. Record Bodily Injury and Treatment

7. Conduct an Investigation

8. Attach Additional Information

9. Sign and Submit

Slip and Fall Incident Report Form – Fill Out and Use This PDF

A Slip Fall Incident Report Sample form is a document used to record all the details of an incident where someone slips and falls on a premises, such as in a store or workplace. It includes information on the incident, claimant, any bodily injuries, witnesses, an investigation of the site, and additional notes or findings that could contribute to understanding what happened and why. This form aids in documenting the circumstances for legal, insurance, and managerial review purposes. To ensure accurate and thorough documentation of a slip and fall incident, it's essential to fill out this form carefully by clicking the button below.

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Slip Fall Incident Report Sample PDF Details

In the event of a slip and fall incident within a store or commercial property, a comprehensive and structured report is essential not only for understanding the circumstances leading to the incident but also for facilitating any potential legal proceedings or insurance claims that might follow. The Slip Fall Incident Report Sample form serves as a crucial tool in this process, meticulously recording necessary details that encompass not only the specific information about the incident—such as the store's name, store number, date, day of the week, time, and exact location—but also descriptive aspects including weather conditions, walking surface conditions, and if the incident was immediately reported. Furthermore, it delves into claimant information which captures personal details, the activity leading up to the incident, and the type and condition of footwear, which could influence the nature of the fall. Bodily injury is addressed by detailing the nature of the injury, any immediate treatment provided, and whether medical facilities were subsequently engaged. The presence and input of witnesses are noted to provide corroborative accounts, while an investigation section prompts an inspection of the site, documentation of the conditions at the time of the incident, including lighting and any preventive measures like caution signs or floor mats. The inclusion of signatures ensures the report's authenticity, underscoring its importance in managing the aftermath of such incidents effectively. This meticulously designed form emphasizes the necessity for a detailed and organized approach to documenting slip and fall incidents, reiterating its significance in establishing clear, factual grounds should further examination or legal action be warranted.

Question	Answer
Form Name	Slip Fall Incident Report
Form Length	2 pages
Fillable?	Yes
Fillable fields	75
Avg. time to fill out	10 min
Other names	fall incident report example, how to write fall incident report sample, slip and fall incident report sample, slip fall incident report form

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SLIP AND FALL INCIDENT REPORT

Weather conditions: Walking surface conditions: Incident reported when it occurred? If no, how was it report/when?

CLAIMANT INFORMATION

Last name:

Age: Sex: Male If no, explain:

	First name:
Female	If minor, was child supervised?	Yes

Address:


Telephone: Home: (_______) _________ - _____________							Business: (_______) _________ - _____________
Why was the customer in store?


What was customer doing prior to the incident:

Type and condition of footwear:


BODILY INJURY
Description of injury:


Treatment given (if any):


Was the injured person taken to medical facility? Yes							No
If yes, where?
How was he or she transported? (name of agency)
Name of attendant:

6311

WITNESSES

Name:			Address:
Phone:			Comments:
Name:			Address:
Phone:			Comments:

INVESTIGATION

Was incident site inspected immediately? Yes

Time:

Inspected by:

How did we find out about the incident?

Describe conditions at scene:

Describe lighting conditions:

Was photograph taken of accident scene? Were floor mats in place?

Condition of mats:

Yes Yes

No No

If floor was wet, were Caution signs in place?	Yes	No
Eye glasses being worn?	Yes	No	If yes, type:
Cane or walker used?	Yes	No	If yes, why?

Was injured taking medication?	Yes	No	If yes, why?

NOTE: include a copy of the daily floor check log for the date of the accident

ADDITIONAL INFORMATION

Additional paperwork attached:

If yes, describe:

Yes

SIGNATURES


Report completed by:		Signature:
Date completed:	Read and approved by:

Disclaimer: This material is designed and intended as general information only. This form was not drafted by an attorney and is not intended, nor shall be 6311

construed or relied upon, as specific legal advice.

How to Edit Slip Fall Incident Report Form Online for Free

Don't know how to write a slip and fall incident report? Simply open our PDF tool and follow the step-by-step instructions below.

Start by entering the basic details of the incident. You can also write the store name and number at the top of the form. Proceed to fill in the date, day of the week, and exact time when the incident occurred.

fall incident report pdf spaces to fill in

In the section provided, give a detailed description of the incident's circumstances. Specify the location and describe what happened, focusing on how the slip or fall accident happened.

Filling out fall incident report pdf step 2

Record any relevant weather conditions that may have contributed to the incident. Also, describe the condition of the walking surface during the fall, noting any factors like wetness or unevenness.

step 3 to completing fall incident report pdf

Indicate whether the incident was reported immediately. If not, provide details on the incident forms, as well as how and when it was reported. Additionally, if any witnesses are present, include their names, addresses, phone numbers, and event accounts.

fall incident report pdf WITNESSES, Name, Phone, Name, Phone, Address, Comments, Address, Comments, Yes, Time, INVESTIGATION, Was incident site inspected, Describe conditions at scene, and Describe lighting conditions blanks to complete

Enter all relevant personal information about the claimant, including last name, first name, age, and sex. Explain the circumstances if the claimant is a minor and was not supervised. Also, detail the claimant’s activity before the incident and describe their footwear.

Describe any injuries sustained from the fall and any immediate medical attention or treatment provided. If the injured person was taken to a medical facility, document where and how they were transported.

fall incident report pdf Was photograph taken of accident, Yes Yes Yes, No No No, If yes type If yes why, Was injured taking medication, Yes, If yes why, NOTE include a copy of the daily, ADDITIONAL INFORMATION, Additional paperwork attached, Yes, and If yes describe blanks to insert

Document if the incident site was inspected immediately after the incident and by whom. Describe the overall conditions of the scene and specific elements like lighting and signage.

If there are additional documents or evidence like photographs or daily floor check logs, note whether these are attached and describe them.

The person completing the report should sign digitally within the online editor. Once all sections are completed, review the document for accuracy, then save your changes. The slip and fall accident form can now be printed for physical records or submitted as required.

Store name:

INCIDENT INFORMATION

Day of week:

Location of incident:

Description of incident: