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 Alessandra Menendez
Home Address 2709 Rainbow Blvd Las Vegas,NV, 89103
D Student D Employee D Visitor D Vendor
Phone Numbers Home 702-403-2221 Cell 702-233-4567 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident 12/18/2017 Time NOW Police Notified  Yes X No

Location of Incident Brightwood Nursing Home

3535 West Sahara Avenue, Las Vegas, Nevada 89102

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 not given vital information about the patient Jane Doe, specifically that the
patient Jane Doe had dementia and would tend to be aggressive toward unfamiliar caregivers. As I was helping her to
retrieve breakfast she got upset as I was helping her stand up, because I was unfamiliar, and proceeded to hit me with her
cane, which she was holding with her left hand, on the left side of my left leg on the knee.

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). No injury only bruising on the left side of knee on the left leg.

Was medical treatment provided?  Yes X No 

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

REPORTER INFORMATION
Individual Submitting Report (print name) Alessandra Menendez

Signature Alessandra Menendez

Date Report Completed 12/18/17

FOR OFFICE USE ONLY

Report Received by Supervisor Jane Got Date 12/18/2017 _

 FOR OFFICE USE ONLY

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

Date Action Taken By Whom

12/18/17 Information now given to health care provider, Alessandra Menendez, Supervisor Jane Got
and different caregiver assigned to patient Jane Doe.