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 Savannah Mohr
Home Address
D Student D Employee Yes D Visitor D Vendor
Phone Numbers Home N/A Cell (209)499-7735 Work N/A

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes  No X
10/14/18 3:00 P.M.
Location of Incident
Memorial Medical Center
1700 Coffee Rd, Modesto, CA 95355
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 was going to go treat a patient and when I went into the room I saw she was
attempting to get up out of her bed. I inquired as to whether she required some assistance and after that quickly when to
go help her. when I attempted to enable her to get to her feet she hit me with her cane in my leg and answered " just let
me do it myself".

Were there any witnesses to the incident?  Yes  No X

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). Back of the leg is bruised.

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

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

REPORTER INFORMATION
Individual Submitting Report (print name)
Savannah Mohr
Signature Savannah Mohr

Date Report Completed 10/14/18

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