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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 JUNELE NEWMAN
Home Address 808 NORTHSHORE JACKSONVILLE, FL 32277
D Student [x] Employee D Visitor D Vendor
Phone Numbers Home Cell 808-627-9172 Work

INFORMATION ABOUT THE INCIDENT


Date of Incident Time Police Notified  Yes [x] No
SEPTEMBER 18,2018 7:30 AM
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 WENT TO GO CHECK ON MRS. LAWRY. I KNOCKED ON HER DOOR FIRST. I WAS ABOUT TO CHECK THE CHART BUT I SAW HER
STRUGGLING TO STAND UP. SO, I OFFERED MY HELP AND THAT’S WHEN SHE HIT ME WITH HER CANE ON MY LEFT LEG.

Were there any witnesses to the incident?  Yes [X] 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).
IT LEFT ME WITH A BIG BRUISE ON MY LEFT LEG.

Was medical treatment provided? [X]Yes  No  Refused


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

REPORTER INFORMATION
Individual Submitting Report (print name)
JUNELE NEWMAN
Signature
JUNELE NEWMAN
Date Report Completed
SEPTEMBER 18,2018

FOR OFFICE USE ONLY

Report Received by DONNA Date 09/19/2018 _


FOR OFFICE USE ONLY

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

Date Action Taken By Whom


09/19/18 CHECKED ON EMPLOYEE’S INJURY DONNA

09/20/18 WENT TO THE PATIENT’S ROOM WITH THE EMPLOYEE DONNA


09/20/18 WENT OVER THE CHART OF THE PATIENT WITH THE EMPLOYEE DONNA