Fall-Down Accident Checklist

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Text in this Example:

Description of the Accident
Description of the accident:
Names, addresses, and phone numbers of all witnesses:
Date of the accident:
Time:
am/pm
Day of week:
Location:
Location of the accident::
Condition of the accident area (e.g. sidewalk);
Photographs of the scene:
Place where the trip began:
Destination:
Purpose of the trip:
Scheduled arrival time:
Fall-Down Accident Checklist
Conditions Surrounding the Accident
Smoking, eating, or drinking at the time of the accident:
Date of last eye examination:
Name and address of the eye doctor:
Use of headphones:
Lightning conditions:
Weather:
Position of the sun:
Use of sunglasses:
Use of alcohol/drugs:
Object carried at time of accident:
Type and condition of shoes:
All conversation at the scene:
Police Involvement
Police district involved:
Name and badge number of attending officer:
Injury
What happened to your body as you fell:
What part of you body came into contact with the ground:
How did you feel immediately after you fell:
Name of health insurance company:
Policy number:
Coverages: