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

Slip Fall Incident Report Sample is a very important document that helps you to file your case against the person responsible for injuring you when you slipped on the floor.

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Slip Fall Incident Report Sample PDF Details

Incidents happen. Whether it is a slip fall on a wet floor, tripping on an uneven surface, or any other type of accident, they can and do occur in the workplace. When they do, it is important to have a process in place for recording and reporting them. A Slip Fall Incident Report Sample Form can help you to do just that. Having such a form can provide a structure for recording key information about the incident, such as when and where it occurred, what caused it, and who was involved. This information can then be used to help investigate the accident and take steps to prevent future occurrences. A sample form can be tailored to meet the specific needs of your workplace, so be sure to tailor yours accordingly.

Here are several details you might want to examine before you begin using the slip fall incident report sample.

Question	Answer
Form Name	Slip Fall Incident Report Sample
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	philadelphia insurance incident, how to write an incident report for nursing home reportables, nursing home incident reporting manual, slip and fall incident report sample

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Form Preview Example

SLIP AND FALL INCIDENT REPORT


Store #:				Store name:
INCIDENT INFORMATION
Date:			Day of week:			Time:
Location of incident:
Description of incident:

AM

PM

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

No

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

No

Time:

:

AM

PM

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

No

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.

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