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 Nioshia Stokes
Home Address 5555 Monroe Ave Hammond, IN 46324
D Student  n Employee D Visitor D Vendor
Phone Numbers j
Home 555-555-5555 Cell 219-307-5245 Work
h
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INFORMATION ABOUT THE INCIDENT
D
Date of Incident Time Police Notified  Yes  No
02/08/2018 12:00 p.m.
Location of Incident
Patient Room 102

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
As I went to check on the patient, Mrs. Lawry, she hit me with the cane because she was anxious and there was a change in
her routine where I was her new care giver which she didn’t recognize.

 Were there any witnesses to the incident?  Yes  No there were no 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).
Yes, knee was injured by cane. Bruises left due to being hit by Mrs. Lawry’s cane.

 Was medical treatment  No  Refused

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

REPORTER INFORMATION
Individual Submitting Report (print name) Nioshia Stokes

Signature Nioshia Stokes

Date Report Completed 02/08/2018

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