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 Nidia C. Barrios
Home Address 1914 Wible Rd, Bakersfield, CA 93304
D Student D Employee D Visitor D Vendor
Phone Numbers Home Cell 661-836-6300 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident 02/26/2018 Time 7:25PM Police Notified  Yes X No

Location of Incident: In patient’s room

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Went into the patient’s room to introduce myself when I saw her trying to get up and move by herself, I went to go see if
she needed any assistance. Patient started to get agitated and I continued to try and calm her down and tell her that I was
there to help her, when she screamed at me and swung her cane at my left leg.

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).
There was a sharp pain when the cane made contact on my left leg, it was hard to walk at first but the pain did ease and
there was bruising afterwards.

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) Nidia C. Barrios

Signature: Nidia C. Barrios

Date Report Completed 02/26/2018

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