Sammi Wolf

6/25/18

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 Molly Sears
Home Address 6468 Hillview Lane Linville, Kentucky 68941
D Student x Employee D Visitor D Vendor
Phone Numbers Home Cell (315) 682-2385 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes X No
4/9/15 8:18 am

Location of Incident
Linville Assisted Living Center
6942 Hillside Lane
Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)

Mrs. Lawry was approached by Ms. Sears at the beginning of the shift to see if she was awake and ready for breakfast.
Ms. Sears saw her struggling to walk and approached her to see if she needed help. Mrs. Lawry then proceeded to hit
Ms. Sears in the side of her leg with the cane multiple times.

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).

Severe bruising to the side of the left leg; no further injuries

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) Donna Simms

Signature

Date Report Completed 4/19/15

FOR OFFICE USE ONLY

Report Received by Date _

Sammi Wolf
6/25/18

FOR OFFICE USE ONLY

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

Date Action Taken By Whom