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 Cora lee Brown
Home Address 1234 brown Street, Lexington Nc 37468
D Student D Employee D Visitor D Vendor
Phone Numbers Home Cell Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes  No
04/08/2018 8:00AM
Location of Incident : The room of mrs. Lowry

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Nurse Brown entered the room and seen that mrs. Lowry was struggling. She offered to help and mrs. Lowry hit her in the
leg 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). Nurse Brown was injured with a sprained knee

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) Cora Brown

Signature Cora Brown

Date Report Completed 04/08/2018

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

04/08/18 Director of facility went in and talked to Lowry Director

04/09/18 Director assigned only two nurses for Lowry Director

- I chose this assignment because knowing how to fill out this incident report is a part of the everyday duties of
a medical assistant. If you don’t know how to fill out a report this could cause big problems in your job. If you
get hurt on the job you only have 24 hours to get this form filled out and to the right person.