Lifting Strain Worksheet
Analysis
Slip and Trip Worksheet Incident No.:
1. What is the exact location of the slip or trip incident? / Building (or nearest):Floor no./hallway:
Stairwell:
Room No:
Sidewalk Location:
Street Name:
Parking Lot Location:
2. Describe the walking surface where the incident occurred: / Tile floor
Carpeted area
Vinyl floor tile
Stone/slate tile
Grass / Asphalt
Concrete
Graveled area
Dirt/mud
Brush/field
3. Describe the grade (incline) of the area: / Flat
Slight
Minimal (3-10 degrees) / Moderate (10-20 degrees)
Steep
Stairs
Are the stairs/steps evenly spaced and uniform?
Yes No-describe:
Which step (from the bottom) did the person fall on?
What is the height (of the step), width (of the stairway), and depth (of the step)?
Ht.: W: D:
5. Describe the condition of the walking surface at the time of the incident: / Greasy
Muddy
Icy
Loose gravel
Loose mat/rug
Dry
Standing water
Wet
Freshly mopped (see below)
Freshly waxed (see below)
What product was used to mop or wax the floor?
Are there problems with using this product (i.e. slippery residue, drying time, etc.):
No Yes – describe:
5. Describe the lighting and visibility in the area at the time of the incident: / Well lighted
Adequately lighted
Poorly lighted
Dim/dark
Visibility obstructed/compromised by:
6. Was the area barricaded or otherwise marked to indicate a hazardous condition? / Yes
No – why not?
Not applicable
7. Describe the object that was tripped over: / Curb
Other raised surface
Floor mat
Electrical cord
Shoestring
Other object (specify):
8. Describe the type of shoes being worn at the time of the incident: / Sandals
Flip Flops
Dress shoes
Tennis shoes
Loafers / Work boots
Slip-resistant safety shoes
Other (specify):
9. Describe the sole of the shoe: / Rubber-soled shoes
Leather-soled shoes
Unknown (smooth)
Unknown (minimal tread)
Unknown (moderate tread)
Unknown (significant tread)
10. Was proper access (i.e. handrails, guardrails, hand-holds) provided at the stairway, ramp, elevated area? / Yes
No
Not applicable
11. What could be done to prevent this incident from reoccurring? / Improve spill control protocols
Implement or improve snow/ice removal practices
Require slip-resistant footwear
Investigate slip-resistant floor coatings/finishes
Install handrails/hand grips
Purchase slip-resistant rugs/mats
Improve lighting
Improve housekeeping
Repair or replace damaged/loose flooring/treads/uneven surfaces
Barricade/sign/mark hazardous areas
Purchase cord protectors
Reinforce proper practices with employees Contact EHSS for coefficient of friction analysis
Other (specify):
Completed by: / Date: