Free Slip Fall Incident Report Template
Slip Fall Incident Report
I. Incident Information
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Date of Incident: May 29, 2050
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Time of Incident: 11:30 AM
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Location of Incident: [Your Company Address]
II. Reporting Details
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Reported By: [Your Name]
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Role/Position: Store Manager
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Report Date: May 29, 2050
III. Incident Description
On the date of May 29, 2050, at approximately 11:30 AM, a customer slipped on a wet floor in the produce section of the supermarket located at [Your Company Address]. The wet floor was a result of a spilled liquid that was not promptly attended to.
IV. Injured Party
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Name: [Customer Name]
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Contact Information: [Contact Info]
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Description of Injuries: The customer sustained injuries to their right ankle and lower back. Immediate medical treatment was provided, and the customer was advised to seek further medical evaluation.
V. Witnesses
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Name: [Witness Name]
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Contact Information: [Contact Info]
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Statement: "I saw the customer slip on the wet floor and fall."
VI. Actions Taken
Immediately after the incident, the customer was assisted by store staff and given first aid. The area was blocked off to prevent further incidents. The spill was cleaned up promptly.
The store manager, [Your Name], documented the incident and advised the customer to seek additional medical attention. All relevant information, including witness statements, has been compiled in this report.
VII. Additional Notes
Security footage of the incident has been reviewed and will be preserved for further investigation. Store policy regarding floor maintenance will be reviewed to prevent future occurrences.
Efforts will be made to ensure all hazards are promptly dealt with to ensure customer safety.
VIII. Signatures
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Reported By: [Your Name]
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Date: May 29, 2050
