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: Diana Jackson
Home Address: 1234 Drury Ln
D Student D Employee D Visitor D Vendor
Phone Numbers Home Cell 8032228979 Work 8032589632

INFORMATION ABOUT THE INCIDENT

Date of Incident 02/02/2018 Time 07:00 Police Notified  Yes  No

Location of Incident: Assisted Living of Storybrook

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Upon entering Mrs. Lawry’s room, I saw she was having difficulty standing to get to the restroom. I offered her my
assistance and tried to hold her by her waist so she would not fall. Mrs. Lawry exclaimed she did not need my help and
struck my left knee with her walking cane.

Mrs. Lawry

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).
Slight contusion to 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) Diana Jackson

Signature

Date Report Completed 02/02/2018

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