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 Gianna Bell
Home Address 1805 Lauren Lane Gettysburg, PA
D Student D Employee D Visitor D Vendor
Phone Numbers Home 487-957-2957 Cell 487-475-9529 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes  No
08/23/2018 1:14 PM
Location of Incident
Mrs. Lawry’s hospital room

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 walked into Mrs. Lawry’s room and I saw that she was struggling to get up from her bed. I immediately walked over to her
and grabbed both arms to help her get some balance and she began screaming “I can do it myself!” She continued to try to
get up on her own but was still really struggling so I went to help again and she began screaming again and she struck me in
the back of my knee with her cane.

Were there any witnesses to the incident? No, there were no witnesses.
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. She hit me in the back of my left knee with her cane.

Was medical treatment provided?  Yes I iced my knee on site.

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

REPORTER INFORMATION
Individual Submitting Report (print name) Gianna Bell

Signature Gianna Bell

Date Report Completed 08/23/2018

FOR OFFICE USE ONLY

Report Received by Marie Rosa Date 08/24/2018 _

 FOR OFFICE USE ONLY

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

Date Action Taken By Whom

08/25/2018 Had conversation with Lawry about aggression towards employees Helen Berk

08/27/2018 Lawry is removed from Gianna’s route Marie Rosa

08/28/2018 Lawry is to be handled with caution Marie Rosa

08/28/2018 Keep her with same nurse so she can get used to having a routine Helen Berk
08/29/2018 Get her walking around more and more physical activity to strengthen Dr. Rosenbom

08/30/2018 Be very patient and understanding of her confusion, keep same routine George Wright
everyday with her