Sample Slips, Trips and Falls Incident Report
When a slip, trip or fall incident occurs, carefully examine the circumstances of the event to see where you can implement prevention measures.
1. What was the first initiating event?
Trip (includes caught on)
Loss of balance
2. Which choice best describes the slips, trips or falls incident?
A slip or trip that did not result in a fall
A fall from an elevation such as:
A fall while standing on a chair;
A fall from a ladder or stepstool;
A fall down stairs or steps;
Other fall from an elevation (describe).
A same-level fall such as:
A fall while walking or working;
A fall from a chair while sitting;
A fall while tripping up stairs;
Other same-level fall (describe).
3. Were there any hazards present that may have contributed to the incident?
Contaminant (examples: water, soap, grease/oil, coffee, wax, slick, slippery not otherwise classified, etc.)
Cord or tubing (examples: hose, medical tubing, phone cord, equipment cords)
Object (examples: objects/items on floor, propped against wall or in the pathway)
Ice or snow
Surface irregularity due to buckled, loose, or damaged mat, carpeting or rug
Surface irregularity, other (examples: some part of the walking surface is irregular, cracked tiles, loose gravel, leaves, door guard, drain dip, hole in floor, hole in landscape)
Bodily reaction (examples: awkward posture, reaching, crouching, bending, carrying something, client or object handling, or just stated as "fell")
Lack of space/restricted pathway
Steps, stairs or handrail
Chair or stool
Inappropriate or malfunctioning footwear
Unknown/no specific hazard mentioned
Other (please specify)