Retail Store Slip-and-Fall Incident Report
Store Location
Date of Incident
Time of Incident
Area/Location Within Store
Name of Person Involved
Phone Number
Email Address
Address
Description of Incident
Describe Any Injuries Sustained
Medical Attention Required?
Yes
No
If yes, describe action taken
Witness Name(s)
Witness Contact Information
Reported To (Employee Name)
Report Date
Report Time
Additional Comments