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 Lisa M Beaver
Home Address 132 I Don’t Know Dr. Jacksonville Fl. 32219
D Student D Employee D Visitor D Vendor
Phone Numbers Home Cell Work 904-000-0000

INFORMATION ABOUT THE INCIDENT

Date of Incident 1/26/18 Time 1:58 pm Police Notified Yes  No

Location of Incident: In the patient’s room

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 in the patient’s room to get them up and ready for breakfast. I walked in and she was trying to get up on her own. I
was thinking she was about to fall because she was shaking and then she didn’t have and shoes on. I approached her, and
she took her cane stick and hit me several times in my knee.

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 the nurse had some bruises on her the right knee

Was medical treatment provided? Yes, No 

Refused
If yes, where was treatment provided: on site Urgent Care  Emergency Room  Other
Lisa Beaver just wanted to ice her knee,
she wanted to return back to work.

REPORTER INFORMATION
Individual Submitting Report (print name) Lisa Beaver

Signature Lisa Beaver

Date Report Completed 1/26/18

FOR OFFICE USE ONLY

Report Received by Mrs. Thomas Date 1/26/18 _

 FOR OFFICE USE ONLY

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

Date Action Taken By Whom

1/27/18 I checked on my Employer to make sure she was ok. Mrs. Thomas

1/31/18 I called the patients family to see if you had any incidents like this Mrs. Thomas
before and if so what was her reason for doing so.
1/31/18 I wrote all the information down in the patients file. Mrs. Thomas