Slip And Fall Incident Report
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1
2SLIP AND FALL INCIDENT REPORT
Store #:
Store name:
INCIDENT INFORMATION
Date:
Day of week:
Time:
AM
PM
Location of incident:
Description of incident:
Weather conditions:
Walking surface conditions:
Incident reported when it occurred?
If no, how was it report/when?
CLAIMANT INFORMATION
Last name:
First name:
Age:
Sex:
Male
Female
If minor, was child supervised?
Yes
No
If no, explain:
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
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Parent category: Business