Restaurant Slip and Fall Incident Report
Employee Information
Employee Name
Job Title
Employee ID
Date of Birth
Contact Information
Incident Details
Date of Incident
Time of Incident
Location in Restaurant
Describe What Happened
Apparent Cause of Slip and Fall
Injury Information
Describe the Injury
Body Part(s) Injured
Medical Attention Required?
Yes
No
Witness Information
Name(s) of Witnesses
Witness Statement(s)
Supervisor/Manager Section
Supervisor/Manager Name
Manager's Additional Comments
Date Reported