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 Anne Lawry
Home Address 867 Easy St
D Student D Employee D Visitor D Vendor
Phone Numbers Home 960-867-1236 Cell 960-867-3456 Work n/a

INFORMATION ABOUT THE INCIDENT

Date of Incident 10/21/18 Time 9:00am Police Notified Yes  No

Location of Incident Beechwood 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)

The nurse was trying to help Mrs. Lawry out of the bed. Mrs. Lawry hits nurse with her cane and says she could 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).

Yes. Bruise on the left knee

Was medical treatment provided?  No  Refused

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

REPORTER INFORMATION
Individual Submitting Report (print name) Shaniqua Cade

Signature

Date Report Completed 10/21/18

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

10/21/18 Reported to police Shaniqua Cade