Retail Store Slip and Fall Incident Report
Date of Incident
Time of Incident
Store Location
Injured Person's Name
Phone Number
Email
Home Address
Description of the Incident
Location of Fall in Store
Contributing Conditions (e.g. wet floor, obstacle, etc.)
Witness Name(s)
Witness Contact Information
Actions Taken by Staff
Was Medical Attention Provided?
Details of Medical Attention
Reported By (Name)
Date
Signature