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 Tracy reed
Home Address 5601 Eden field rd.
D Student X Employee D Visitor D Vendor
Phone Numbers Home na Cell 9042588198 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident 01/31/2018 Time 8:00 Police Notified Yes  *No

Location of Incident: 12000 beach Blvd. room 89 bed b

Jacksonville FL 32216

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 was going in room 89 to check on one of the new patients, I knocked, entered and she struck me in the knee with her
Cain. My knee instantly began to throb and pain shot through it on the left side.

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 injuries. My left knee was throbbing and swollen I could barely walk. It was not noted
that the patient is in the beginning stages of dementia and is combative.

Was medical treatment provided?  No  Refused

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

REPORTER INFORMATION
Individual Submitting Report (print name) Tracy Reed

Signature Tracy Reed

Date Report Completed 1/30/2017

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