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Patient fall incident report example

Patient fall incident report example 2026

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The document is a Slip and Fall Incident Report Form from Philadelphia Indemnity Insurance Company, designed to collect detailed information about incidents occurring on premises. It includes sections for claimant and witness information, incident details, bodily injury descriptions, corrective actions, and supervisor's reports. The form emphasizes the importance of thorough investigation and documentation to prevent future incidents and improve safety measures.

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Click ‘Get Form’ to open the patient fall incident report in the editor.
Begin by filling out the Claimant Information section. Enter the name, address, and location of the incident. Include details for both witnesses, such as their names and phone numbers.
In the Incident Information section, specify the date and time of the incident. Clearly describe how it occurred and provide witness accounts.
Analyze contributing factors in the Analysis section. Document any unsafe conditions or acts that led to the incident.
Outline Corrective Actions taken or planned to prevent future incidents.
Ensure all signatures are collected from the claimant and witnesses, along with dates for each signature.
Complete the Bodily Injury Information section by detailing the cause of injury and any medical treatment provided.

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