Professional Documents
Culture Documents
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.
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 in the patient’s room to get them up and ready for breakfast. I walked in and she was trying to get up on her own. I
was thinking she was about to fall because she was shaking and then she didn’t have and shoes on. I approached her, and
she took her cane stick and hit me several times in my knee.
REPORTER INFORMATION
Individual Submitting Report (print name) Lisa Beaver
Document any follow-up action taken after receipt of the incident report.
1/31/18 I called the patients family to see if you had any incidents like this Mrs. Thomas
before and if so what was her reason for doing so.
1/31/18 I wrote all the information down in the patients file. Mrs. Thomas