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 Vivian Aviles
Home Address 1468 Dreary Lane, Riverside, California 97462
D Student X Employee D Visitor D Vendor
Phone Numbers Home (909) 457-5862 Cell Work
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INFORMATION ABOUT THE INCIDENT
Date of Incident Time Police Notified  Yes X No
03/24/2018 11:45 am
Location of Incident
Beachwood Manor

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Was hit in the leg with a cane by a patient. I was helping the patient back onto the bed and the patient got angry yelled and
hit me with the cane in the leg.

Were there any witnesses to the incident?  Yes X 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, in the leg. No lacerations, no open wounds, a bruise and a redness

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

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

REPORTER INFORMATION
Individual Submitting Report (print name)
Vivian Aviles
Signature

Date Report Completed

03/26/2018

FOR OFFICE USE ONLY

Report Received by Date _

 FOR OFFICE USE ONLY

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

Date Action Taken By Whom

3/25/2018 Removed from patient’s care Head Nurse