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 |
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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 |
SLIP AND FALL INCIDENT REPORT
Store #: |
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Store name: |
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INCIDENT INFORMATION |
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Date: |
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Day of week: |
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Time: |
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Location of incident: |
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Description of incident: |
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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:
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First name: |
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Female |
If minor, was child supervised? |
Yes |
No
Address:
Telephone: Home: (_______) _________ - _____________ |
Business: (_______) _________ - _____________ |
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Why was the customer in store? |
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What was customer doing prior to the incident: |
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Type and condition of footwear: |
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BODILY INJURY |
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Description of injury: |
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Treatment given (if any): |
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Was the injured person taken to medical facility? Yes |
No |
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If yes, where? |
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How was he or she transported? (name of agency) |
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Name of attendant: |
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WITNESSES
Name: |
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Address: |
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Phone: |
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Comments: |
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Name: |
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Address: |
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Phone: |
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Comments: |
INVESTIGATION
Was incident site inspected immediately? Yes |
No |
Time: |
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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 |
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Eye glasses being worn? |
Yes |
No |
If yes, type: |
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Cane or walker used? |
Yes |
No |
If yes, why? |
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Was injured taking medication? |
Yes |
No |
If yes, why? |
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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: |
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Signature: |
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Date completed: |
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Read and approved by: |
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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.