PA Slip and Fall Incident Report Form 2001-2025 free printable template

Philadelphia Indemnity Insurance Company Page 1 of 2 One Ball Plaza, Suite 100, Ball Crowd, PA 19004 4/2001 Slip and Fall Incident Report Form Claimant Information Name: Address Location of Incident:

How to fill out slip and fall incident report sample form

How to fill out PA Slip and Fall Incident Report Form

1. Start the form by entering the date and time of the incident.
2. Provide the exact location where the slip and fall occurred.
3. Describe the nature of the incident: what happened and how it happened.
4. Include details about the weather conditions at the time of the incident, if relevant.
5. List any witnesses to the incident, including their names and contact information.
6. Document any injuries sustained, including specifics about the injury and medical attention received.
7. Sign and date the form to verify the information provided.

Who needs PA Slip and Fall Incident Report Form?

1. Individuals who have experienced a slip and fall incident and are seeking to report it.
2. Property owners or managers who need to document incidents for liability purposes.
3. Insurance companies that require the report for claims processing.
4. Legal representatives who may need the report for litigation or settlement.

Video instructions and help with filling out and completing agency federal

Instructions and Help about fall incident report sample

Welcome to how to and ECS this video will cover the instant report charting screen to open the insert report charting screen first select the residence name from the main list then select the button marked incidents at the bottom of the third column on the nurses main access screen this will open the incident accidents access screen click the button marked fall / incident at the top of the charting column this will open the incident report charting screen to begin select one of the incident types listed then enter the residents mental status at the time of the incident then indicate the location of the resident at the time of the incident following the location is the description of events at the beginning of description events you will select the residents position the activity at the time of the incident and equipment involved in the incident then click the button marked description narrative and enter a description of what occurred and what was found at the time of the incident following the description of events is the injury assessment here you will indicate if any injuries were more received at the time of the incident if an injury was received select the type of injury and then in the dialogue box and turn the description of that injury if no injuries were apparent at the time of the incident click the button marked no apparent injury following the injury assessment is the hour two questions did the resident hit their head indicate yes or no and then is the resident on an anticoagulant or antiplatelet here can answer yes or no following these questions is the first aid section indicate if first day was applied if you click immediately apply it enter it in the dialog box what first aid was provided if tanks were to the emergency room was indicated select transfer to emergency room and if no first aid was needed select none note needed following first aid are possible causes this is where you enter the residents' statement first click the button that says resident States and type in what the resident says happened at the time of the incident if the resident is unable to communicate you can skip the resident state section and enter any other possible causes for the incident after possible cause select Footwear then select who the first responder was to the incident if there were any witnesses to indicate whether it was a staff member a family member or visitor you'll be prompted to enter the name of the staff member family member or visitor and if it is a staff member even we have prompted to enter the title if there were no witnesses click none following witnesses you will then need to click the button marked actions and enter it in the dialogue box what actions you took at the time of the incident in the immediate interventions you will collect the purple button and then in the dialog box enter in what interventions you put into place at the time of the incident future actions is for entering any teaching you provided to the resident as...

People Also Ask about nursing patient fall incident report example

How do you write a patient fall incident report?

Filling Out an Effective Incident Report Include the full names of those involved and any witnesses, as well as any information you have about how, or if, they were affected. Add other relevant details, such as your immediate response—calling for help, for example, and notifying the patient's physician.

How do you write an incident report form?

Provide date and time of the incident and when it was first reported, details of witnesses, and a succinct statement describing the events leading to the incident, the details of the incident, the type of work being undertaken, any hazards involved in the work and any personal protective equipment being used.

How do you write an incident report on a fall on a nursing home?

What Information Do You Put in an Incident Report? Detailed description of the event with events listed chronologically. Witnesses or injured party statements. Injuries sustained by the person(s) as a result of the incident or the outcome. Actions taken immediately after the incident occurred. Treatments administered.

What is incident report format?

An incident report should include the following details: The person affected and their contact information. A factual description of the incident, including location, date, and time. A description of the incurred injuries if any. Any involved parties or witnesses and their contact information.

How is a patient incident report written?

Document any unusual occurrences that you witnessed. Record the events and the consequences for the patient in enough detail that administrators can decide whether or not to investigate further. Write objectively, avoiding opinions, judgments, conclusions, or assumptions about who or what caused the incident.

What should be written on an incident form?

What should you include in an incident report? When & where did it happen? Your report should contain the date, time and location where the accident took place. Who were involved? What did they do? Why did it happen? Were there any witnesses? What is the extent of damage to a person or property?

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What is PA Slip and Fall Incident Report Form?

The PA Slip and Fall Incident Report Form is a document used to record details of slip and fall accidents that occur on a property in Pennsylvania. It captures information about the incident, the individuals involved, and any witnesses.

Who is required to file PA Slip and Fall Incident Report Form?

Typically, property owners, managers, or employees who witness or are involved in a slip and fall incident are required to file the PA Slip and Fall Incident Report Form.

How to fill out PA Slip and Fall Incident Report Form?

To fill out the PA Slip and Fall Incident Report Form, provide accurate details such as the date and time of the incident, the location, description of the circumstances, contact information for those involved, and any witnesses, along with any photographic evidence if available.

What is the purpose of PA Slip and Fall Incident Report Form?

The purpose of the PA Slip and Fall Incident Report Form is to document the facts surrounding the slip and fall incident for legal, insurance, and safety improvement purposes. It helps identify hazards and prevent future accidents.

What information must be reported on PA Slip and Fall Incident Report Form?

The information that must be reported includes the date and time of the incident, the specific location, names and contact information of the individuals involved, details of the incident circumstances, any injuries sustained, and names and contact information of witnesses.