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 Tempest Jackson
Home Address 4526 Mossburn Ave Charlotte, NC 28212
D Student YES Employee D Visitor D Vendor
Phone Numbers Home Cell (704)642-6435 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident February 21, 2018 Time 10:35 am Police Notified No

Location of Incident
Beechwood Manor

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 entered Mrs. Lawry room to see if she needed any assistance and to invite her to breakfast as Donna stated she came in a
little edgy and confused. As I was helping Mrs. Lawry because I walked in and she was trying to get off the bed, she hit me
with her cane on my left leg

Were there any witnesses to the incident?  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, Mrs. Lawry hit my left leg which resulted in my left knee becoming swollen

Was medical treatment provided?  Yes

If yes, where was treatment provided: On site

REPORTER INFORMATION
Individual Submitting Report (print name) Tempest Jackson

Signature

Date Report Completed: February 27, 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

February 27, Make sure before any treatment is done the patients file is read
2018 thoroughly
Try to have the members who care for the patient stay the same if they
have memory issues & are aggressive
Make sure any healthcare member reads the patient chart before
engaging with them