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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 Aimee Miller
Home Address 5678 Breezy Lane Pensacola, FL 32533
D Student D Employee D Visitor D Vendor
Phone Numbers Home Cell Work

INFORMATION ABOUT THE INCIDENT


Date of Incident Time Police Notified  Yes xNo
29 January 2018 10:50 am
Location of Incident
Beachwood Manor 312 East Nine Mile Rd Pensacola, FL 32514

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Nurse Aimee went into Ms. Lawry’s room to introduce herself and tried to help her up. Ms. Lawry then struck the nurse in
the left knee 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, Bruise to the left knee

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


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

REPORTER INFORMATION
Individual Submitting Report (print name) Supervisor A. Person

Signature

Date Report Completed 29 January 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


29 Jan 2018 Employee follow-up at ER self

01 Feb 2018 Patient counselled on hitting the employees self


01 Feb 2018 Nurse Aimee’s work comp paperwork turned in A. Miller