Raven Cotton

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: Symone Bridges
Home Address: 164 Laurel Hill Dr, Burlington, NC 27125
D Student D Employee D Visitor D Vendor
Phone Numbers Home Cell 3364176452 Work 3363345789

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes  No
1/13/18 3.43 pm
Location of Incident
Mrs. Lawry’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 to go to Mrs. Lawry’s room to introduce myself and see if she wanted to get up for breakfast. As I knocked on the
door and proceeded to enter I noticed that she was about to fall, so I placed my hands on her shoulders to try catch her
balance. I said “let me help you” and she got upset and said “just let me do it on my own”, then hit me in my left calf 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, a bruised left lower leg (calf area)

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)
Symone Bridges
Signature
Symone Bridges
Date Report Completed
1/13/18

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

Be sure to read patients file first nurse

Find out more about patient and relay it to staff supervisor

Get nurses leg checked out On site nurses

Talk to Mrs. Lawry about her actions and try to make her feel more supervisor
comfortable