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

Erica Kane
1234 Sesame Street Hammond Indiana 46324
D Student Y Employee D Visitor D Vendor
Phone Numbers 219-554-1234 219-554-5678 219-588-2300

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified yes  No
4-6-18 7:00 am
Location of Incident
Manor Beach Hospital

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

Upon my arrival to work I consulted with the supervisor to get any updates on patients. She alerted me about
Mrs. Lawry, who had just come in by ambulance from a nursing facility. The supervisor was busy catching up on her work
load, So I offered to give her a helping hand by checking to see if Mrs. Lawry was ready to get up for breakfast. I entered
her room and happened to notice that she was sitting on the side of the bed trying to stand up while holding her cane in
her right hand. I asked her if she wanted my help, which seemed to upset her, and she struck me on my left leg in the knee
area with her walking 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 was injured by way of a strike with Mrs. Lawry’s walking cane to the left knee area and sustained significant bruising.

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)
Donna Johnson, Supervisor
Signature

Date Report Completed

4-6-18

FOR OFFICE USE ONLY

Report Received by Donna Johnson, Supervisor Date 4-6-18 _

 FOR OFFICE USE ONLY

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

Date Action Taken By Whom

4-7-18 Patient was checked on more often to avoid getting out of bed. Erica Kane