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 jane doe
Home Address 123 main st Philadelphia PA 19111
D Student D* Employee D Visitor D Vendor
Phone Numbers Home Cell Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes *No
August 27, 2018 10:00 am
Location of Incident
Manor Bay Facilities

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 attacked by Mrs Lowry with her cane. I was going in her room to check and see was she ok for breakfast, I noticed she
was trying to get out the bed and was struggling to walk or move it look as if she was going to fall. So, I went to help her sit
down and she struck me in my leg 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). Yes my knee was damaged.

Was medical treatment provided?  No  Refused

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

REPORTER INFORMATION
Individual Submitting Report (print name) Jane Doe

Signature Jane Doe

Date Report Completed

August 28, 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