INCIDENT REPORT

Date (when the incident occurred)

: October 20, 2014

Time

: 11:00 am

Name

: Samuela V. Manda

Home Address
Bukidnon

: Phase 3, B-8, L-4, Casisang, Malaybalay City,

INJURY
Type of Bodily Injury

: Right Wrist Fracture

Location of the incident

: Market Site, Brgy. 9, Malaybalay City, Bukidnon

Describe exactly what happened:

The incident happened when I was walking at the market to buy vegetables and
meat. I unintentionally slipped off my right foot at a side-road cement causing me to fall
sideways. As a defense to avoid knocking down my head, I used my right hand to maintain
balance which caused the injury.
Emergency medical treatment given?

_____ Yes _____ No

Name of hospital

: Bukidnon Provincial Hospital

Describe procedure(s)

: A fiber cast was installed on my right arm in order to

avoid further damage due to a cortical break in my right
wrist

Cost of injury

: I incurred P2,000 for the operation but subject for

increment as I have to undergo follow-up check up after
the removal of the fiber cast

Signed by:

Samuela V. Manda