Professional Documents
Culture Documents
Incident Report Form
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.
Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
• Today I came into work and Donna told me that we had a new patient by the name of Mrs. Lawry. She looked a
little stressed and I was not here yesterday when the information about her was given. As a result, I offered to go
and help her with what was needed. When I walked in I seen that she was struggling to walk and offered to help
her with getting up as I went to help she hit me in the knee with her cane.
REPORTER INFORMATION
Individual Submitting Report (print name): Johanna Arana
Document any follow-up action taken after receipt of the incident report.