Jennifer Rubio

12-19-17

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 Rubio
Home Address: 679 Myrtle rd. Turlock 95402
D Student D Employee D Visitor D Vendor
Phone Numbers Home 2093586001 Cell 2096765433 Work 2093412929

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes  No
12-19-17 6:13 a.m.
Location of Incident
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 went into her room to introduce myself and ask if she wanted breakfast, but I noticed her struggling to get up. So, I went
towards her asking if she needs help and I tried to help her not fall, she then hit me with her cane.

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).

I got a swollen, bruised left leg.

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 Rubio
Signature
x
Date Report Completed
12-19-17

FOR OFFICE USE ONLY

Report Received by Date _

This assignment took me 23 minutes.

Jennifer Rubio
12-19-17
FOR OFFICE USE ONLY

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

Date Action Taken By Whom

Take care of nurses’ leg. Nurses

Talk to Ms. Lawry and tell her that the nurse she hit was her new nurse. Supervisor

Apologize to the injured nurse for not warning her about the stuff in Supervisor
Ms. Lawrys’ file.
Be sure to read the patients file when you are assigned to be their new Injured nurse
nurse.
Tell Ms. Lawry to try to stay more calm when new people show up. Supervisor

This assignment took me 23 minutes.