Fall Incident Form 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.

QuestionAnswer
Form NameSlip Fall Incident Report Sample
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesphiladelphia insurance incident, how to write an incident report for nursing home reportables, nursing home incident reporting manual, slip and fall incident report sample

Form Preview Example

Philadelphia Indemnity Insurance Company

One Bala Plaza, Suite 100, Bala Cynwyd, PA 19004

Slip and Fall Incident Report Form

Page 1 of 2

4/2001

Claimant Information

Name:

Address

Location of Incident:

Name of Witness #1:

Phone # of Witness #1:

 

Sex M F

 

Age

 

 

 

 

 

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Task being Performed:

Name of Witness #2:

Phone # of Witness #2:

Incident Information

Incident date:

/

/

Day of week:

 

Time:

:

AM PM

 

 

 

 

 

 

 

 

 

 

Location of incident?

Was incident reported when it occurred?

Yes

No

Describe Clearly How the Incident Occurred:

Witnesses Account of Incident:

Analysis (What Acts and / or conditions directly contributed to the incident?):

Corrective Action (What actions have or will be taken to prevent recurrence):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Claimant:

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

Signature of Witness #1:

 

 

Date:

 

Signature of Witness #2:

 

 

Date:

 

 

 

 

 

 

 

 

 

 

Bodily Injury Information

Cause of injury:

 

 

 

 

 

 

 

Describe unsafe

 

 

 

 

 

 

 

conditions or unsafe

 

 

 

 

 

 

 

 

 

 

 

 

 

acts:

 

 

 

 

 

 

 

Client injured by:

 

Self-inflicted

Staff member

Other member

 

Incident Occurred:

 

Entering facility

Inside of facility

While exercising

 

 

Exiting facility

Outside of facility

Other:

 

 

 

 

 

 

 

 

 

 

 

 

Specific area where

 

 

 

 

 

 

 

incident occurred:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of injury:

 

Abrasion/scratch

Fracture/break

Sprain/strain

 

The information and suggestions presented by Philadelphia Indemnity Insurance Companies in this loss control technical resource form are for your consideration in your loss prevention and risk control efforts. They are not intended to be complete in identifying or reporting on every possible or significant hazard at your premises, preventing possible workplace accidents, or complying with all of the local, state or federal health & safety related laws or regulations. The material enclosed within this loss control reference source is intended and encouraged to be altered or redesigned by you to specifically address your hazards.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2 of 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contusion/bruise

Laceration/cut

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

First Aid treatment by Staff

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

Action Taken:

Referred to Doctor

Referred to nurse

 

 

Transported to hospital:

(Doctor’s Name:

 

 

Nurse’s Name:

 

 

 

Name of hospital:

 

 

 

 

 

 

 

 

 

 

 

 

Person Notified:

 

 

 

Time Notified:

 

 

AM

PM

 

 

 

 

 

 

 

Treatment Provided:

None

First aid

 

 

Medical office visit

Emergency room /outpatient

Inpatient services

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

Abdomen

Eye

 

 

Leg

 

Arm

Foot / toes / ankle

 

 

Mouth / Teeth

Part of body injured:

Back

Hand / fingers

 

 

Neck

 

Chest

Head / skull

 

 

Nose

 

Ear

Knee

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisor's Report of Accident

Manager / Supervisor’s Name:

Basic Rules for Incident Investigation

•Find the cause to prevent future incidents - Use an unbiased approach during investigation

•Interview witnesses & injured employees at the scene - conduct a walkthrough of the incident

•Conduct interviews in private - Interview one witness at a time.

•Get signed statements from all involved.

•Take photos or make a sketch of the incident scene.

•What hazards or unsafe conditions are present - what unsafe acts contributed to accident

•Ensure hazardous conditions are corrected immediately.

Supervisor's Root Cause Analysis

Check ALL that apply to this incident

Unsafe Acts

By-passing or avoiding safety devices

Drug or alcohol use

Entered area without authority

Failure to warn (no warning signs)

Horseplay

Improper maintenance of area

Insufficient knowledge of area

Moving at improper speeds

Safety rule violation

Other:

Re-Training Assigned

Re-Training Completed

Supervisor Signature:

Unsafe Conditions

Damaged flooring, tiles or surfaces

Inadequate guarding of hazards

Insufficient lighting

Lack of flooring covering (mats)

Lack of safety devices (handrails)

Obstructed view

Poor housekeeping

Poor surface conditions

Slippery / wet conditions (spills)

Tripping hazards / congestion in area

Other:

Date

 

 

Date

Unsafe Condition Guarded

Unsafe Condition Corrected

Date:

The information and suggestions presented by Philadelphia Indemnity Insurance Companies in this loss control technical resource form are for your consideration in your loss prevention and risk control efforts. They are not intended to be complete in identifying or reporting on every possible or significant hazard at your premises, preventing possible workplace accidents, or complying with all of the local, state or federal health & safety related laws or regulations. The material enclosed within this loss control reference source is intended and encouraged to be altered or redesigned by you to specifically address your hazards.

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