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 Empyema Calderon
Home Address 5050 Chestpain Lane Chicago Il, 60623
D Student x Employee D Visitor D Vendor
Phone Numbers Home 312-588-3700 Cell 312-588-3700 Work 219-836-6770

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes X No
06/04/18 1600
Location of Incident
Mrs. Lawry room 313

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Went to Mrs. Lawry’s room to introduce myself knocked on door & noticed patient standing up with cane but unsteady at
side of bed then I went to help her & placed my hands on both shoulders to help her keep balance Patient states “to just let
her do it” then proceeded to hit me on my left knee cap with 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).
Injury to left knee cap

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) Empyema Calderon

Signature Empyema Calderon

Date Report Completed 06/04/18

FOR OFFICE USE ONLY

Report Received by Jessica Fromm Date 06/04/18 _

 FOR OFFICE USE ONLY

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

Date Action Taken By Whom

06/04/18 Placed bed alarm on pt. to inform if pt. attempting to get out of bed Nursing staff Amie M
without help
06/14/18 Reorient pt. to self & place Nursing staff Amie M