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 Presidents Office.

INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT

Full Name Halee Ann Leblanc
Home Address 39 East Park Street
Student Employee Visitor Vendor
Phone Numbers Home Cell 228-236-8140 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified Yes No
11/27/17 1:11 pm
Location of Incident
Memorial Hospital

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 arrived to work. Got a brief description on the new patient. Went to introduce myself and to see if she
wanted to get up and eat breakfast. When i opened the door, the patient was trying to stand on her own.
I went to assist her and she hit my left leg 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).

YES, I was injured. Small bruise on my knee.

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)
Halee Leblanc
Signature

Date Report Completed 11/27/17

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

11/27/17 Better warning signs on file and door or room. Bed alarm turned
on