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 Jennifer Jerrold
Home Address 1234 north ave
D Student x Employee D Visitor D Vendor
Phone Numbers Home Cell (559)795-7473 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident 6/20/18 Time 8:00am Police Notified  Yes X No

Location of Incident
Resident’s room 313

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary). As I was coming on shift I got an update on a new patient in room 313 Mrs. Lawry.
My supervisor Dona was distracted because she was having to take care of running the station plus the staff and did not
give a lot of information on the new resident Mrs. Lawry, so I went to room 313 to introduce myself and to see if she
wanted to get up and have some breakfast. As I knock to enter the room I found the resident trying to get out of bed and
walk with her cane. Mrs. Lawry was wobbly and could hardly stand up on her own. I immediately went over to Mrs. Lawry
and asked if she needed any help and that is when she hit me in the left leg with her cane and said “I do not need any
help.”

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 the individual was injured in the left leg around the 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) Jennifer Jerrold

Signature Jennifer Jerrold

Date Report Completed 6/20/18

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

Should have checked to see if the nurse was okay

Should have stated to look at the notes before entering the room

Should have taken the time to go over the care plan for Mrs. Lawry with
the new nurse.