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 Mary Ubaldo
Home Address 4567 Flower st. 8954 Las Vegas, NV
D Student * Employee D Visitor D Vendor
Phone Numbers Home785-566-5221 Cell Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes *No
8/23/18 12:37
Location of Incident
Beach Wood Manor room 13

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Was not told that patient was violent. Went into room to introduce myself. Seen Mrs. Lwary trying to put her slippers on so
I tried to help but she did not need my help and hit me 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, bruised in the back of the left leg on the calve

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) mary ubaldo

Signature mary Ubaldo

Date Report Completed 8/23/2018

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