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 |
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:
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Phone Number |
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Task being Performed:
Name of Witness #2:
Phone # of Witness #2:
Incident Information
Incident date: |
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Day of week: |
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Time: |
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AM PM |
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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):
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Signature of Claimant: |
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Date: |
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Signature of Witness #1: |
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Signature of Witness #2: |
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Bodily Injury Information
Cause of injury: |
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Describe unsafe |
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conditions or unsafe |
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acts: |
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Client injured by: |
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Staff member |
Other member |
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Incident Occurred: |
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Entering facility |
Inside of facility |
While exercising |
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Exiting facility |
Outside of facility |
Other: |
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Specific area where |
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incident occurred: |
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Type of injury: |
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Abrasion/scratch |
Fracture/break |
Sprain/strain |
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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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Page 2 of 2 |
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Contusion/bruise |
Laceration/cut |
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Other: |
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None |
First Aid treatment by Staff |
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Other: |
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Action Taken: |
Referred to Doctor |
Referred to nurse |
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Transported to hospital: |
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(Doctor’s Name: |
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Nurse’s Name: |
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Name of hospital: |
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Person Notified: |
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Time Notified: |
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Treatment Provided: |
None |
First aid |
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Medical office visit |
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Emergency room /outpatient |
Inpatient services |
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Other: |
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Abdomen |
Eye |
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Leg |
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Arm |
Foot / toes / ankle |
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Mouth / Teeth |
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Part of body injured: |
Back |
Hand / fingers |
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Neck |
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Chest |
Head / skull |
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Nose |
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Ear |
Knee |
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Other: |
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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
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:
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 |
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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.