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 Anais Luna
Home Address 1211 Nevada Ave
D Student x Employee D Visitor D Vendor
Phone Numbers Home (209) 987-3253 Cell (209) 586-2409 Work (209) 555-3000

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified X Yes  No
04/22/18 12:35pm
Location of Incident
Beachwood Manner

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Residents was struggling to get out of bed , I then insisted on helping patient get out of bed and patient aggressively hit
nurse the side of her left leg.

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).
Body part injured in the incident was my left leg , the leg injured was hit by a cane .

Was medical treatment provided?  Yes X No  Refused

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

REPORTER INFORMATION
Individual Submitting Report (print name) Anais Luna

Signature

Date Report Completed 04/22/18

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