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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.
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 was not given vital information about the patient Jane Doe, specifically that the
patient Jane Doe had dementia and would tend to be aggressive toward unfamiliar caregivers. As I was helping her to
retrieve breakfast she got upset as I was helping her stand up, because I was unfamiliar, and proceeded to hit me with her
cane, which she was holding with her left hand, on the left side of my left leg on the knee.
REPORTER INFORMATION
Individual Submitting Report (print name) Alessandra Menendez
Document any follow-up action taken after receipt of the incident report.