Slip Fall Incident Report Sample PDF Details

Slip and fall incidents are prevalent in public and private areas, varying from minor to severe falls that can lead to serious injuries. These occurrences are typically classified as situations where a person loses their footing or balance because of a dangerous situation in the area. Everyday dangers include slippery or frosty floors, uneven ground, dimly lit spaces, and unforeseen barriers.

It is crucial to have precise documentation of these incidents. A thorough incident report gives a truthful description of the event and aids in comprehending the factors that led to its occurrence. Our slip and fall incident report sample includes the following:

- Date and time of incident. When the incident happened.

- Fall accident scene. Specific details about where the incident took place within the facility or property.

- Incident description. A detailed narrative of the events leading up to, during, and immediately following the fall.

- Surface conditions. Wet floors, uneven surfaces, poor lighting, or any other relevant environmental factors where the fall occurred.

- Witness information. Names and contacts of people who saw the incident or were present at the scene.

- Injuries sustained. Details about any injuries that resulted from the fall, including the type and severity.

- Immediate actions. What was done right after the incident, such as providing first aid to injury victims or calling for medical treatment?

- Photographic evidence. Whether photographs of the incident scene were taken to provide visual evidence of the conditions.

Organizations can identify and rectify hazardous conditions by analyzing fall reports, thus preventing future incidents. A detailed fall report form also supports an injury claim, ensuring that all parties receive fair compensation.

Note that it is essential to report the incident promptly. Delays can affect records' accuracy as memories fade and can affect legal and insurance processes. Prompt documentation ensures that every detail is accurately recorded and that institutional or legal standards are efficiently met.

Why Use Our Slip and Fall Incident Report Example?

Using a slip and fall incident report template is invaluable for organizations aiming to handle such accidents effectively and systematically. Our form standardizes the reporting process, ensuring all the necessary details are documented consistently and accurately. This consistency is crucial when the incident reports are used for legal defense or insurance claims.

A well-planned template can also simplify the documentation procedure, enabling employees to efficiently and accurately fill out the forms. It can be especially advantageous in situations of high stress when it may be challenging to remember all necessary information. Templates help businesses avoid costly mistakes in liability or compliance with safety regulations by offering clear prompts and organized sections.

Additionally, using our fall incident report sample improves an organization's capacity to evaluate accidents over time. Consistent data gathering enables the detection of patterns and problems, making it easier to implement more decisive preventive actions.

QuestionAnswer
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

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 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.

1. Fill in Basic Incident Details

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

2. Describe the Incident

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

3. Document Environmental Conditions

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

4. Report Timing and Witnesses

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

5. Provide Claimant Information

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.

6. Record Bodily Injury and Treatment

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

7. Conduct an Investigation

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.

8. Attach Additional Information

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

9. Sign and Submit

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.

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