DCAM/RISK MGMT – FORM 001be (06/2019)
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Claim Number
Slip and fall
Was the person distracted? Yes No If so, by what?
How did the person fall? Forward Backward Other
What part(s) of the body was injured?
Was the person talking to someone? Yes No Were there children present? Yes No
Was the person a client of the place where the incident occurred? Yes No
Was the surface wet, oily, dirty, slippery, etc.? Wet Oily Slippery Dirty Other
Were danger or caution signs posted? Yes No If so, what?
Was there a transition in walkway surfaces, or any tripping hazards? If so, explain
Was weather (rain/snow) a factor in the incident? If so, describe
Was site cleanup needed? (spill, dirt, etc.)? Yes No Describe
How long after first notice was incident cleaned up?
Type of footwear worn? athletic shoes sandals high heels flats other
Type of material of shoe heel? rubber leather synthetic other
Did footwear contribute to the fall? Yes No Explain
Machinery incidents
Was injury due to machinery? Yes No If so, who was operating?
What type of machinery was involved in the incident?
Policy/procedure regarding operation of machinery? Yes No Operator trained? Yes No
Machinery last service date? Machinery last safety inspection?
Were safety features in place? (guards, chains etc?) Yes No Explain
General questions
Type of terrain? (i.e. flat, hilly, grassy gravel?)
Area inspected/cleared of debris and safety hazards?
Did you speak to a witness? Yes No If so, what was said?
Was assistance provided? Yes No If so, what? by whom?
Non-medical personnel called to accident site? Yes No
If so, who?
Was the incident reported to local authority? If so, provide police report.
No Yes
Attach additional shee
t, if needed.
By signing this form you are attesting the information contained is accurate.
Employee signature Date Risk coordinator signature Date
Employee name printed Coordinator name printed
