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 Presidents Office.

INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT

Full Name Michelle L Cruz
Home Address 5421 W Red Ribbon Rd Fort Worth, TX 76179
Student Employee Visitor Vendor
Phone Numbers Home 817-820-6431 Cell 817-462-7946 Work 817-886-7415

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified Yes No
11/22/2017 8:15am
Location of Incident

Beechwood Manor Nursing Home

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 Michelle, had just reported to work for my shift and spoke with the head Nurse Donna about any updates or new information in the office. She proceeded to inform me
that we have a new patient named Ms. Lawry. I proceeded to Ms. Lawry's room to introduce myself and see how she was adjusting. As I walked into her room, I noticed
she was up so I proceeded to walk towards her asking if she needed any assistance, she then struck me with her cane. I was hit on my left leg by my knee. I fell to the floor
and called out for help; Donna came in and helped me out the room.

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 experienced pain, soreness and bruising on my left leg.

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)
Michelle Cruz
Signature

Date Report Completed

11/22/2017

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