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 Samanta B Swindle
Home Address 1234 Main St Jacksonville, Fl 32210
D Student [x] Employee D Visitor D Vendor
Phone Numbers Home Cell (904)123-4567 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes [x]No
09/19/2018 7:30am
Location of Incident
Beachwood Manor patient room 313

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 introduce myself when I saw she was trying to get out of bed by herself. I walked up to
her to try and help her and she said, “Just let me do it on my own!” and then hit me on the side of my left 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).

Yes, I had some tenderness and bruising on the outer side of my knee of my left leg.

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

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

REPORTER INFORMATION
Individual Submitting Report (print name) Samanta B Swindle

Signature Samanta B Swindle

Date Report Completed 09/19/2018

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

09/20/2018 Training refresher for all employees. Jane Smith

09/20/2018 Next shift change send the next nurse in to introduce his/herself with Jane Smith
the nurse from the previous shift to avoid patient confusion.