Slip, Trip, and Fall Incident Questionnaire Form
Please complete this form to document details of a slip, trip, or fall event. Your responses help ensure appropriate follow-up and workplace safety.
Date and time of the incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of the incident
*
Full name of the person involved
*
First Name
Last Name
Role or relationship to the organization
*
Please Select
Employee
Visitor
Contractor
Other
Describe what happened
*
Contributing conditions (select all that apply)
Wet or slippery surface
Obstruction or debris
Poor lighting
Uneven flooring
Other
Immediate actions taken after the incident
Injuries or damage observed
Names of witnesses (if any)
Contact information for follow-up (email or phone)
*
Submit Incident Report
Should be Empty: