Housekeeping Slip-and-Fall Incident Report

Incident Details

Date of Incident Time of Incident Location Area/Room Number

Person Involved

Contact Information Department

Incident Description

Describe what happened Was the area wet or slippery? Yes No Unknown Floor condition (e.g., wet, dry, oily, cluttered) Footwear worn

Injuries Sustained

Describe injuries First Aid Provided? Yes No If yes, by whom

Witnesses

Witness Name(s) Contact Information

Reporting Staff

Name Date