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Incident Form

This incident report form is used to document accidents, injuries, medical situations, or behavior incidents at the campus. The form provides spaces to record information about the person involved in the incident, details of the incident including location, description, witnesses, and injuries. It also includes information about the individual submitting the report and has a section for documenting any follow up actions taken. Miranda Moreno completed this form to report an incident where an elderly resident, Mrs. Lawry, accidentally hit Miranda's knee with her cane when Miranda was assisting her out of bed. No medical treatment was refused but Mrs. Lawry received treatment at the emergency room.

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125 views2 pages

Incident Form

This incident report form is used to document accidents, injuries, medical situations, or behavior incidents at the campus. The form provides spaces to record information about the person involved in the incident, details of the incident including location, description, witnesses, and injuries. It also includes information about the individual submitting the report and has a section for documenting any follow up actions taken. Miranda Moreno completed this form to report an incident where an elderly resident, Mrs. Lawry, accidentally hit Miranda's knee with her cane when Miranda was assisting her out of bed. No medical treatment was refused but Mrs. Lawry received treatment at the emergency room.

Uploaded by

api-415321301
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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 Miranda Moreno
Home Address 1234 w fresno lane
D Student D Employee D Visitor D Vendor
Phone Numbers Home 5595751380 Cell Work

INFORMATION ABOUT THE INCIDENT


Date of Incident 06/20/2018 Time 8:46 am Police Notified  Yes X No

Location of Incident Brightwood

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 Mrs. Lawry’s room to check to see if she would like any breakfast. When I walked in I saw that she was trying
to get out of bed and walked, so I asked if she would like any help. When I went over to assist her she hit my knee with her
cane.

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).

Was medical treatment provided?  No  Refused


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

REPORTER INFORMATION
Individual Submitting Report (print name) Miranda Moreno

Signature Miranda Moreno

Date Report Completed 06/20/2018

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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