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 Keyasha Toombs
Home Address 1022 chestnut ave.
D Student D Employee D Visitor D Vendor
Phone Numbers Home Cell 7065932156 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes  No
9/18/18 5:30 pm
Location of Incident
Beachwood manor

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 in the room to introduce myself to the new patient and I noticed she was having trouble sitting down. I offered to
help her out and she hit me on the knee with her cane and insisted I let her do it herself.

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).

No, I wasn’t seriously injured.

Was medical treatment provided?  Yes  No  Refused

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

REPORTER INFORMATION
Individual Submitting Report (print name)
Keyasha toombs
Signature
Keyasha Toombs
Date Report Completed
9/18/18

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