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 Kayla Jackson
Home Address 220 Strawberry Ln
D Student * Employee D Visitor D Vendor
Phone Numbers Home 803-353-2610 Cell 803-250-7894 Work 803-776-4545 ext. 5630

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified *Yes  No
1/29/18 11:30 AM
Location of Incident
7546 hardway st, Columbia sc, 29223 Medical Park 3

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 trying to help the patient in bed and she hit me with her telephone and began yelling she can do it herself. I let her go
and stood beside the bed to make sure that she was okay and able to do it herself.

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).
Yes, I received a head injury. I was cut and also had a knot where the telephone impacted.

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) Kayla Jackson

Signature Kayla Jackson

Date Report Completed 1/29/18

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

1/29/18 Supervisor came in and took over Supervisor

1/29/18 I was sent to the medical office for treatment Supervisor

1/29/18 I later returned under knowledge of not touching the patient. Allow Supervisor
patient to move on her own and supervise.