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: Kassandra Cervantez
Home Address: 1303 E Herndon Ave, Fresno, Ca 93720
D Student D Employee D Visitor D Vendor
Phone Home Cell Work (559)450-3000
Numbers:(559)
INFORMATION ABOUT THE INCIDENT
Date of Incident Time Police Notified  Yes  No
6/20/18 8:47am
Location of Incident
Saint Agnes Medical Center, patient rooms

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

Patient has dementia, and diabetes, also has a history of being aggressive with anybody she encounters. I went to see if
patient needed help and she got aggressive with me then hit my left knee with a 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).

Employee may have a sprain on left knee but nothing serious.

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) Kassandra Cervantez

Signature Kassandra Cervantez

Date Report Completed 6/20/18

FOR OFFICE USE ONLY

Report Received by Kassandra Cervantez Date 6/20/18 _

 FOR OFFICE USE ONLY

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

Date Action Taken By Whom