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 Elizabeth Stevens
Home Address 123 Rodger St. Milton, FL 32570
D Student D Employee D Visitor D Vendor
Phone Numbers Home Cell Work

INFORMATION ABOUT THE INCIDENT

Date of Incident 1-29-18 Time 10:50 am Police Notified  Yes  No

Location of Incident 312 E. Nine Mile Rd. Pensacola, FL 32514

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Employee was trying to assist Mrs. Sally Lawry stand-up from her bed. Mrs. Lawry didn’t give the employee permission to
touch her and became agitated and struck the employee on knee.

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).
Bruised left 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) Ragina McMiller

Signature Ragina McMiller

Date Report Completed 1-29-18

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

1-29-18 Educated Employee on proper patient interaction Self

1-30-18 Employee had follow-up from ER Self

1-30-18 Spoke with patient about not hitting Self