Fall Incident Questionnaire
Help us improve safety by providing detailed feedback on fall incidents.
Patient Name
*
First Name
Last Name
Date of Injury
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where did the accident occur?
Approx what time?
Where you Indoors or Outdoors
Indoors
Outdoors
Please describe exactly how the fall happened.
*
What specific condition caused the fall?
*
Did you see the condition before you fell?
*
Yes
No
Is there anything that may have affected your ability to see or avoid the condition?
Is there any indication how long the dangerous condition existed before the fall?
Did anyone associated with the property know about the condition before the fall?
*
Yes
No
Was the incident documented?
Incident report
Photographs/video of the condition
Photographs/video of the injuries
Surveillance cameras nearby
Witnesses
Employee/manager witnesses
Police/EMS/fire-rescue response
Other
FOR ATTORNEYS
Is there Med-Pay
Yes
No
Unsure
Claim #
Carrier Name
Carrier Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
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