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 Nicole Scott
Home Address: 5216 Beverly Drive Carmel, Florida 57212
D Student D Employee - YES D Visitor D Vendor
Phone Numbers Home: 317-625-4521 Cell: 317-389-6245 Work: 317-956-2378

INFORMATION ABOUT THE INCIDENT

Date of Incident: Time: Police Notified  Yes  No
May 05, 2017 7:43 am
Location of Incident:
Beechwood Manor
2214 Mann Drive Beech Grove, South Carolina 46182
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 into Mrs. Lawry’s room to ask if she wanted to go get breakfast. I noticed that she was trying to get out of bed,
but I noticed she was having difficulty standing upright. I asked her if she needed any assistance. She then said “No, I can do
it on my own.” That’s when she took her cane and hit it hard against my femur. Causing a significant amount of pain,
swelling, and bruising.

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).
After visiting the doctor, he confirmed that my femur had been shattered. As well as a ligament had been torn. Due to the
injuries he has ordered me to be in a leg boot and brace for the next month and a half.

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)
Jane Nicole Scott

Signature:
Jane Nicole Scott
Date Report Completed:
May 05, 2017

FOR OFFICE USE ONLY

Report Received by: Donna Mackenzie Date: May 05, 2017

 FOR OFFICE USE ONLY

Document any follow-up action taken after receipt of the incident report.

Date Action Taken By Whom

May 05, 2017 Filed work compensation for Ms. Scott Dr. Brown

May 06, 2017 Started Investigating Incident Dr. Wheeler

May 10, 2017 Evaluated Mrs. Lawry state of mind Dr. Lloyd

May 13, 2017 Started therapy for Ms. Scott Dr. Toler
May 19, 2017 Had meeting with staff about Mrs. Lawry’s evaluation results Dr. Garcia