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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 Brandon David De La Garrigue
Home Address 1313 Dancer St Moreno Valley, CA 92553
D Student X Employee D Visitor D Vendor
Phone Numbers Home (951)653-2918 Cell (951) 293-7979 Work N/A

INFORMATION ABOUT THE INCIDENT


Date of Incident Time Police Notified  Yes X No
07/23/2018 4:24 PM
Location of Incident

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 went into Mrs. Lawry’s room when I noticed she was having trouble trying to stand up. When I tried to assist her, Mrs.
Lawry got very anxious and aggravated and yelled “let me do it on my own”, she then hit my leg with her cane.

Were there any witnesses to the incident?  Yes X 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).
Leg was bruised from the cane.

Was medical treatment provided?  No  Refused


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

REPORTER INFORMATION
Individual Submitting Report (print name)
Brandon De La Garrigue
Signature
Brandon D.
Date Report Completed
07/23/2018

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


7/24/2018 Let everyone know if a patient is aggressive so they can be treated by Supervisor
an experienced caretaker.
7/29/2018 Have training for those who can be more experienced when handling Supervisor
elderly patients
8/3/2018 Provide more information on documentation if patient’s have Supervisor
abnormal behavior