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 Sally Lawry
Home Address 5678 Breezy Lane
D Student D Employee D Visitor D Vendor
Phone Numbers Home850-478-6789 Cell Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes  No
January 29, 2018 10:50 am
Location of Incident
Beachwood Manor 312 E. Nine Mile Road Pensacola FL, 32514 850-484-1234

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)

Person went in to assist Ms. Lawry with getting up. Person did not ask permission to assist patient, which resulted
to person being hit with a cane in the 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).
Person had a bruised 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) Supervisor

Signature Rahzaela Frank

Date Report Completed January 29, 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

01/29 Educate employee on proper patient interaction Supervisor

01/30 Follow up visit with ER ER

01/31 Patient Counseled Supervisor

Rahzaela Frank
Mrs. Asbury
AH102