Dairy Parlor Slip and Fall Incident Form
Date of Incident
Time of Incident
Incident Location (within parlor)
Person Involved (Name)
Position/Role
Witnesses (if any)
Describe how the incident occurred
Describe the floor surface condition (e.g., wet, uneven)
Footwear Worn
Injury Details (if any)
First Aid/Treatment Given
Incident Reported To
Corrective Actions Taken/Recommended
Person Completing Report
Date