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 Presidents Office.

INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT

Full Name Sofia Velazquez
Home Address 602 S Beach Blvd apt 21 Anaheim Ca 92705
Student X Employee Visitor Vendor
Phone Numbers Home 714-373-4575 Cell Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified Yes x No
11/20/2017 7:10 am
Location of Incident

Beachwood Hospital 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)

I offered to check and offered something to eat on patient Mrs Lawry, when I walked into the room, Mrs. Lawry was trying to stepped
out from the bed, she seems upset, shaking and a little confused. I aproached her and offered my help but Mrs Lawry refused it
by kicking me on my left leg with her cane, and exclaiming "NO".

Were there any witnesses to the incident? Yes x 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, pain and a slightly bruise

Was medical treatment provided? Yes x No Refused

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

REPORTER INFORMATION
Individual Submitting Report (print name) Jamie Angeles

Signature J a m i e A n g e l e s

Date Report Completed 11/20/2017

FOR OFFICE USE ONLY

Report Received by __________________________________________________ 11/20/2017

Date _________________________________
 FOR OFFICE USE ONLY

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

Date Action Taken By Whom

11/21/2017 Report any condition on her behavoir changes Medical Assistants

11/21/2017 Meet Mrs. Lawry daughters to know her likes and dislikes Supervisor

11/21/2017 Report glucose levels. Mrs Lawry is Diabetic Medical Assistants

Try not to change the care providers Supervisor