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    Incident Report Form: Briyana Ross

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    An incident report form was completed to report an incident involving Briyana Ross, an employee, being hit with a cane by a patient on March 23, 2018 at 11:12 am at Beachwood Manor 123 Key St Macon Ga 31206. Briyana offered to help the patient who was struggling to get her balance but the patient hit Briyana in the left leg with her cane, bruising her leg. No other witnesses were present and medical treatment was not provided for the bruise. The completed form was submitted to the President's Office by Briyana Ross on the date of the incident.

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    Incident Report Form: Briyana Ross

    Uploaded by

    api-400870738
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    An incident report form was completed to report an incident involving Briyana Ross, an employee, being hit with a cane by a patient on March 23, 2018 at 11:12 am at Beachwood Manor 123 Key St Macon Ga 31206. Briyana offered to help the patient who was struggling to get her balance but the patient hit Briyana in the left leg with her cane, bruising her leg. No other witnesses were present and medical treatment was not provided for the bruise. The completed form was submitted to the President's Office by Briyana Ross on the date of the incident.

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    An incident report form was completed to report an incident involving Briyana Ross, an employee, being hit with a cane by a patient on March 23, 2018 at 11:12 am at Beachwood Manor 123 Key St Macon Ga 31206. Briyana offered to help the patient who was struggling to get her balance but the patient hit Briyana in the left leg with her cane, bruising her leg. No other witnesses were present and medical treatment was not provided for the bruise. The completed form was submitted to the President's Office by Briyana Ross on the date of the incident.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    56 views2 pages

    Incident Report Form: Briyana Ross

    Uploaded by

    api-400870738
    An incident report form was completed to report an incident involving Briyana Ross, an employee, being hit with a cane by a patient on March 23, 2018 at 11:12 am at Beachwood Manor 123 Key St Macon Ga 31206. Briyana offered to help the patient who was struggling to get her balance but the patient hit Briyana in the left leg with her cane, bruising her leg. No other witnesses were present and medical treatment was not provided for the bruise. The completed form was submitted to the President's Office by Briyana Ross on the date of the incident.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    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 Briyana Ross
    Home Address 2298 Ingleside Drive Macon Ga 31204
    D Student x Employee D Visitor D Vendor
    Phone Numbers Home 478-798-1238 Cell 478-978-2298 Work 478-741-1956

    INFORMATION ABOUT THE INCIDENT


    Date of Incident Time Police Notified  Yes X No
    March 23, 2018 11:12
    Location of Incident
    Beachwood Manor 123 Key St Macon Ga 31206

    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 walked into the room to check on the patient and interduce myself. I see that she was struggling trying to get
    balance and I offered to help her. She than hit me with her cane in the 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).
    Left leg, Bruised

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


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

    REPORTER INFORMATION
    Individual Submitting Report (print name): Briyana Ross

    Signature: Briyana Ross


    Date Report Completed: March 23, 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

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