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 Sally Lawry
Home Address 5678 Breezy Lane Pensacola FL, 32533
D Student D Employee D Visitor D Vendor
Phone Numbers Home8504786789 Cell Work

INFORMATION ABOUT THE INCIDENT

Date of Incident 1/29/2018 Time 10:50AM Police Notified  Yes  No

Location of Incident Beachwood Manor 312 E. Nine Mile Rd Pensacola FL 32514

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Person entered Lawry’s room and began assisting her with standing up without letting her acknowledge first. Lawry then
stuck Person 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).
Person leg was bruised.

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) Supervisor

Signature Kelana Collins

Date Report Completed 1/29/2018

FOR OFFICE USE ONLY

Report Received by Supervisor Date 1/29/2018 _

 FOR OFFICE USE ONLY

Document any follow-up action taken after receipt of the incident report.

Date Action Taken By Whom

1/29/2018 Educated employee on proper assistance Supervisor

1/30/2018 Follow up visit w/ ER ER

1/31/2018 Patient counseled Supervisor