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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 trafc incident should be reported directly to the Campus Public
Safety ofce.) If possible, the report should be completed within 24 hours of the event. Submit
completed forms to the President’s Offce.

INFORMATION ABOUT PERSON INVOLVED IN
THE INCIDENT
Full Name Corey Nathaniel Day
Home Address 333 Natomas Blvd. Sacramento, CA 95835
☐ Student ☒ Employee ☐ Visitor ☐ Vendor
Phone Home Cell (666)666-6666 Work
Numbers
INFORMATION ABOUT THE INCIDENT
Date of Incident Time Police ☐Yes ☒No
2-27-2018 12:15pm Notified
Location of Incident
Room 313 of Beachwood Manor

Description of Incident (what happened, how it happened, factors leading to the event,
etc.) Be as specifc as possible
(attached additional sheets if necessary)
I went to our new resident’s room “Ms. Lawry” who has a history of aggression when there is a
change in care provider or routine to introduce myself and get her to come out for breakfast. I
announced myself, and began to walk into the room and noticed her struggling to get up, I asked
“may I help you?” and began to put my hands on her shoulder to assist her. I unknowingly seemed
to have upset Ms. Lawry and she exclaimed “JUST LET ME DO IT!” and smacked the side of my left
leg with her walking 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).
Slight bruising to left leg

Was medical treatment ☒No ☐Refused
provided? ☐Yes If yes, ☐on site ☐Urgent ☐Emergency ☐Other
where was treatment Care Room
provided:
REPORTER INFORMATION
Individual Submitting Report (print name) Corey Day

Signature Corey Day

Date Report Completed 2-27-2018

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

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