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Incident Report Form: Information About Person Involved in The Incident

This incident report form is used to document accidents, injuries, medical situations, or behavior incidents involving students or employees. The form requests information about the individual involved, including their name, address, and contact details. It also requests details about the incident, including the date, time, location, description of what happened, whether there were any witnesses, if the individual was injured and the extent of their injuries, if medical treatment was provided, and the reporter's information. The form is then submitted to the President's Office and any follow up actions are documented.

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281 views2 pages

Incident Report Form: Information About Person Involved in The Incident

This incident report form is used to document accidents, injuries, medical situations, or behavior incidents involving students or employees. The form requests information about the individual involved, including their name, address, and contact details. It also requests details about the incident, including the date, time, location, description of what happened, whether there were any witnesses, if the individual was injured and the extent of their injuries, if medical treatment was provided, and the reporter's information. The form is then submitted to the President's Office and any follow up actions are documented.

Uploaded by

api-427872139
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

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 Cierra Patillo
Home Address 36 First Avenue Atlanta, Ga
D Student DI’m the Employee D Visitor D Vendor
Phone Numbers Home Cell Work

INFORMATION ABOUT THE INCIDENT


Date of Incident Time Police Notified  Yes  No
9/17/2018 9:00 am No police
Location of Incident involved
Nursing Home

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
While helping the patient get off of the bed, she became very aggressive and swung her cane and it me in the side of the
left knee.

Were there any witnesses to the incident?  Yes  No, there wasn’t any witnesses.
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 was not 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) Cierra Patillo

Signature Cierra Patillo

Date Report Completed 9/17/18

FOR OFFICE USE ONLY

Report Received by Donna Date 9/17/18 _


FOR OFFICE USE ONLY

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

Date Action Taken By Whom


Donna should have told the day shift nurses about the patient’s behavior.

Donna could’ve introduced the patient to the new nurse.


Document the patient’s behavior.

Reassure the patient that she is in good hands.

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