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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 Jane Doe
Home Address 111 Oak Dr. McDavid FL 32568
D Student D Employee D Visitor D Vendor
Phone Numbers Home n/a Cell 850-382-0000 Work 850-354-2222

INFORMATION ABOUT THE INCIDENT
Date of Incident 03/22/2018 Time 6:20pm Police Notified  Yes  No

Location of Incident Bay Side Manor Care Center

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
After arriving on evening shift Nurse Jane Doe entered Patient Sue Browns room to check on her. Nurse Doe Noticed Ms.
Brown struggling to get out of her bed and put her hands on Ms. Doe to assist her in standing. Ms. Brown became startled
and confused and struck Nurse Doe in the left knee with her cane. Ms. Brown has dementia and does not like change to her
environment and becomes stressed.

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).
Nurse Doe received bruising and swelling of her left 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) Stephanie Johnson

Signature Stephanie Johnson

Date Report Completed 03/22/2018

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
03/22/2018 Meeting with staff to stress that you always inform the patient when you will be On Duty Nurse
touching them.
03/24/2018 Ensure that all information of patient is recorded and each attending staff Oak Manor Supervisor
reads the chart daily.