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Philadelphia Indemnity Insurance Company

One Bala Plaza, Suite 100, Bala Cynwyd, PA 19004

Page 1 of 2 4/2001

Slip and Fall Incident Report Form

Claimant Information

Name: Address Location of Incident: Name of Witness #1: Phone # of Witness #1: Sex M F Phone Number Task being Performed: Name of Witness #2: Phone # of Witness #2: Age

Incident Information

Incident date: / / Day of week: Location of incident? Was incident reported when it occurred? Describe Clearly How the Incident Occurred: Time: Yes No : AM PM

Witnesses Account of Incident:

Analysis (What Acts and / or conditions directly contributed to the incident?):

Corrective Action (What actions have or will be taken to prevent recurrence):

Signature of Claimant: Signature of Witness #1: Signature of Witness #2:

Date: Date: Date:

Bodily Injury Information

Cause of injury:

Describe unsafe conditions or unsafe acts:

Client injured by: Incident Occurred: Specific area where incident occurred:

Self-inflicted Entering facility Exiting facility

Staff member Inside of facility Outside of facility

Other member While exercising Other:

The information and suggestions presented by Philadelphia Indemnity Insurance Companies in this loss control technical resource form are for your consideration in your loss prevention and risk control efforts. They are not intended to be complete in identifying or reporting on every possible or significant hazard at your premises, preventing possible workplace accidents, or complying with all of the local, state or federal health & safety related laws or regulations. The material enclosed within this loss control reference source is intended and encouraged to be altered or redesigned by you to specifically address your hazards.

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Type of injury:

Abrasion/scratch Contusion/bruise

Fracture/break Laceration/cut First Aid treatment by Staff Referred to nurse Nurse's Name: Time Notified: First aid Inpatient services Eye Foot / toes / ankle Hand / fingers Head / skull Knee

Sprain/strain Other: Other: Transported to hospital: Name of hospital: AM PM Medical office visit Other: Leg Mouth / Teeth Neck Nose Other:

None Referred to Doctor Action Taken: (Doctor's Name: Person Notified: Treatment Provided: None Emergency room /outpatient Abdomen Arm Back Chest Ear

Part of body injured:

Supervisor's Report of Accident

Manager / Supervisor's Name: Basic Rules for Incident Investigation · Find the cause to prevent future incidents - Use an unbiased approach during investigation · Interview witnesses & injured employees at the scene - conduct a walkthrough of the incident · Conduct interviews in private - Interview one witness at a time. · Get signed statements from all involved. · Take photos or make a sketch of the incident scene. · What hazards or unsafe conditions are present - what unsafe acts contributed to accident · Ensure hazardous conditions are corrected immediately.

Supervisor's Root Cause Analysis

Check ALL that apply to this incident

Unsafe Acts

By-passing or avoiding safety devices Drug or alcohol use Entered area without authority Failure to warn (no warning signs) Horseplay Improper maintenance of area Insufficient knowledge of area Moving at improper speeds Safety rule violation Other: Date Re-Training Assigned Re-Training Completed

Supervisor Signature:

Unsafe Conditions

Damaged flooring, tiles or surfaces Inadequate guarding of hazards Insufficient lighting Lack of flooring covering (mats) Lack of safety devices (handrails) Obstructed view Poor housekeeping Poor surface conditions Slippery / wet conditions (spills) Tripping hazards / congestion in area Other: Date Unsafe Condition Guarded Unsafe Condition Corrected

Date:

The information and suggestions presented by Philadelphia Indemnity Insurance Companies in this loss control technical resource form are for your consideration in your loss prevention and risk control efforts. They are not intended to be complete in identifying or reporting on every possible or significant hazard at your premises, preventing possible workplace accidents, or complying with all of the local, state or federal health & safety related laws or regulations. The material enclosed within this loss control reference source is intended and encouraged to be altered or redesigned by you to specifically address your hazards.

Information

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