This customizable document, Visitor Fall Incident Investigation Report Form, is taken from MCN Healthcare’s Ambulatory Services Environment of Care Manual. For more than 20 years, MCN has been the health care industry’s leading provider of policy and procedure templates, forms, competencies and other compliance tools.

MCN provides more than 80 health care specific policy and procedure manuals for Acute Care Hospitals, Ambulatory Care, Behavioral Health, Home Health, Physician Practice, and Long Term Care. MCN’s policy and procedure manuals focus on the latest healthcare "hot topic" issues related to patient safety and prevention of medical healthcare errors.

Here is some sample content from Visitor Fall Incident Investigation Report Form:

	VISITOR FALL INCIDENT INVESTIGATION REPORT Report Number: Date: Name: Address: Date and Time Incident Occurred: Location of Incident: Weather Conditions: Lighting Conditions: Hazards present on walking surface: Reason stated for being at facility: Apparent physical condition of victim: Describe victims attire at time of incident: Describe shoes worn at time of incident: Was victim carrying anything at time of incident? What was victim doing at the time incident occurred? Describe incident: Witnesses: Name: Address: Interview: Name: Address: Interview: Was victim a minor?...
Second excerpt:
	... If yes, was victim accompanied by parents? If no, was anyone responsible for controlling the child? Was victim treated in the Emergency Department? List names of the physician and hospital who treated patient: Did any employee or staff member make any promises to victim? Who made the promise? What was the promise? Was promise verified with employee or staff member? Explain: Investigator Narrative: Signature of Investigator: Report Reviewed By: VISITOR FALL INCIDENT...