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 Destiny Saunders
Home Address 9999 Lucks Ln. Midlothian, VA 23112
Student Employee Visitor Vendor
Phone Numbers Home 8045559876 Cell 8045552938 Work 8045558273

INFORMATION ABOUT THE INCIDENT

Date of Incident 3/25/18 Time 7:30 A.M. Police Notified  Yes  No

Location of Incident Beechwood Manor- Room 313

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary): I come in for my shift and stop at the nurse’s station to talk to my supervisor
and ask her how the morning is going. She tells me about a new resident (Mrs. Lowery) arriving late last night from the
hospital and that the paramedics have her medical records, so she hasn’t been able to look them over. I ask her if she
knows how she’s doing this morning and she tells me, “I spoke to Jane at shift change and she told me she was confused,
didn’t sleep well and is a little edgy but that’s normal.” I then tell her I’m going to go introduce myself and see if she wants
to get up for some breakfast. I knock on Room 313 where Mrs. Lowery is, ask her if I can come in and open the door. Upon
opening the door, I see her trying to stand up on her own with her cane, shaking and struggling. I run in and ask her if I may
help her, to which she replies, “Just let me do it on my own.” as I’m helping her back onto the bed. She then proceeds to hit
me in my left knee with her cane.

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. Bruising to left knee.

Was medical treatment provided?  No  Refused

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

REPORTER INFORMATION
Individual Submitting Report (print name) Destiny Saunders

Signature Destiny Saunders

Date Report Completed 3/26/18

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