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: Brandy Haynes
Home Address: 1234 Rockhurst Court
D Student X Employee D Visitor D Vendor
Phone Numbers Home: (213) 503-5893 Cell: (213) 001-7856 Work: (213) 712-9946

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified xYes  No
6/20/2018 6:45pm
Location of Incident
Parkview Hospital Medical Center “3865 Jackson street Riverside, California 92503

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 assigned to check on this patient “Dorris Lawry”. So, I Waked into the patient’s room to check on her and
when I opened the door I see Mrs. Lawry trying to get up by herself. Looks like she was struggling so I reached over to help
her. As I stepped close to her and tried to help she yelled “YOU JUST LET ME DO IT ON MY OWN” and smacked my left 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).

Was medical treatment provided?  Yes  No  Refused

If yes, where was treatment provided: X on site Urgent Care  Emergency Room  Other

REPORTER INFORMATION
Individual Submitting Report (print name) Brandy Haynes

Signature B………..h……..

Date Report Completed 6/20/2018

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

6/21/2018 X- Rays on my left leg Physician