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: Carolina Vargas
Home Address: 3224 Gettysburg ln
D Student D Employee D Visitor D Vendor
Phone Numbers Home Cell: 6825520837 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident: 1/29/18 Time: 7:17 Police Notified  Yes  No

Location of Incident: 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)
Once I entered the room, I wanted to see how Mrs. Lawry was doing. Once I seen that she was standing and having trouble
trying to walk, I tried to hold her arm by helping her walk. She refused to my help and hit me with a cane right on the side
of the 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).
The patient wasn’t injured.

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) Carolina Vargas

Signature

Date Report Completed:1/29/18

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

1/29/18 Go to the doctor to get a follow up on the knee The doctor

1/29/18 Have ways to approach the patient without getting any more damages. The nurses
1/29/18 Tell employers about the patient and preventions from aggression The Supervisor

1/29/18 Re check about the patient before approaching them The nurses
1/29/18 Making sure all employers are trained in a situation like this The Supervisors