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.

QuestionAnswer
Form NameSlip Fall Incident Report Sample
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfall incident report example, how to write fall incident report sample, slip and fall incident report sample, slip fall incident report form

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.

How to Edit Slip Fall Incident Report Sample Online for Free

The nursing home incident reporting manual completing course of action is quick. Our software lets you work with any PDF document.

Step 1: Choose the "Get Form Here" button.

Step 2: The file editing page is presently available. It's possible to add text or manage present content.

Enter the content required by the system to fill in the file.

fall incident report pdf spaces to fill in

Please type in the crucial details in the Sex, Male, Female, If minor was child supervised, Yes, First name, Last name, Age, If no explain, Address, Telephone Home, Business, Why was the customer in store, What was customer doing prior to, and Type and condition of footwear space.

Filling out fall incident report pdf step 2

It's essential to provide specific information inside the area Treatment given if any, Was the injured person taken to, Yes, If yes where, How was he or she transported name, and Name of attendant.

step 3 to completing fall incident report pdf

The WITNESSES, Name, Phone, Name, Phone, Address, Comments, Address, Comments, Yes, Time, INVESTIGATION, Was incident site inspected, Describe conditions at scene, and Describe lighting conditions segment should be applied to record the rights or obligations of both sides.

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

Finalize by looking at all of these sections and submitting the required data: 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.

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

Step 3: Press "Done". Now you can transfer your PDF file.

Step 4: Produce duplicates of your file. This will prevent potential future problems. We do not check or share the information you have, therefore you can relax knowing it is protected.

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