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 Alyssa De La Cruz
Home Address 3235 Peach Dr. Fresno, CA 93726
D Student D Employee D Visitor D Vendor
Phone Numbers Home Cell (559) 555-555 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes x No
06/20/2018 8:47am
Location of Incident
Brightwood

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 approached Mrs. Lawry and as I tried to help her get up, she hit be 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).
Mrs. Lawry injured my knee, giving me a deep cut.

Was medical treatment provided?  Yes xNo 

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

REPORTER INFORMATION
Individual Submitting Report (print name) Alyssa De La Cruz

Signature Alyssa De La Cruz

Date Report Completed 06/20/2018

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