Slip and Fall Incident Report
Store Information
Store Name
Store Location/Address
Date of Incident
Time of Incident
Person Involved
Full Name
Phone Number
Email Address
Role
Customer
Employee
Contractor
Other
Age
Incident Details
Location within Store (aisle, section, etc.)
Describe what happened
Surface Condition (wet floor, debris, etc.)
Any Warning Signs Present?
Yes
No
Injuries and Assistance
Describe any injuries
First Aid Provided?
Yes
No
Emergency Services Contacted?
Yes
No
Witnesses
Name(s) and Contact Information
Additional Comments
Report Completed By (Name)
Date