Incident Report Form

Use this form to report accidents, injuries, medical situations, or student behavior incidents. (Incidents involving a crime or
traffic incident should be reported directly to the Campus Public Safety office.) If possible, the report should be completed
within 24 hours of the event. Submit completed forms to the President’s Office.

INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT

Full Name Tiffany Michelle Rios
Home Address 4915 Baymeadows Rd. 10-F, Jacksonville, FL 32217
 Student D Employee D Visitor D Vendor
Phone Numbers Home Cell Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified Yes  No
1/30/2018 9:45
Location of Incident: Beachwood Manner
5940 Beach Blvd, Jacksonville, FL 32207

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)

When entering Ms. Lawry’s room, I introduced myself as her new caregiver for the day. However, I believe I startled her,
because she didn’t know who I was. I walked up to her and I tried assisting her on her way to the restroom. That is when
she hit me quite forcefully in the knee wither walking stick.

Were there any witnesses to the incident?  Yes  No

If yes, attach separate sheet with names, addresses, and phone numbers.
Was the individual injured? If so, describe the injury (laceration, sprain, etc.), the part of body injured, and any other
information known about the resulting injury(ies).

Yes, I was injured. I was hit in the knee.

Was medical treatment provided?  Yes  No  Refused

If yes, where was treatment provided:  on site Urgent Care  Emergency Room  Other

REPORTER INFORMATION
Individual Submitting Report (print name) Tiffany Rios

Signature Tiffany Rios

Date Report Completed 1/30/2018

FOR OFFICE USE ONLY

Report Received by Ms. Cassie Ice Date 1/30/2018

 FOR OFFICE USE ONLY

Document any follow-up action taken after receipt of the incident report.

Date Action Taken By Whom

2/5/2018 New training began for the employee to avoid future incidents Ms. Ice