Slip And Fall Incident Report Page 2
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1
2WITNESSES
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?
Yes
No
Were floor mats in place?
Yes
No
Condition of mats:
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:
Yes
No
If yes, describe:
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
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construed or relied upon, as specific legal advice.
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