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: Fernando Sanchez
Home Address: 18695 Caminito Cantilena Unit 202, San Diego, CA 92128
D Student X Employee D Visitor D Vendor
Phone Numbers Home Cell 858-231-7268 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident: Sep. 24, 2018 Time: 4:45 Police Notified  Yes X No

Location of Incident: Room 103

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 went into Mrs. Lawry’s room to introduce myself; I ask if she wanted some to eat for breakfast, but I noticed her struggling
to get up on her own. So, I went towards Mrs. Lawry asking if she needs help and I tried to help her not fall. Suddenly, she
then hits me 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).

I has have resulted with a swollen, bruised leg.

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)
Fernando Sanchez
Signature
X
Date Report Completed
Sep. 24, 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

9/24/18 Take care of swollen bruised leg Nurses

9/25/18 Speak to Mrs. Lawry to let her know the nurse was injured and was Supervisor
supposed to be her new nurse