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: Johanna V Arana
Home Address: 22333 Second Ct
D Student D Employee D Visitor D Vendor
Phone Numbers Home Cell: 559-567-6322 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident: 06/20/2018 Time: 8:54 a.m. Police Notified  Yes xNo

Location of Incident: Brightwood

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
• Today I came into work and Donna told me that we had a new patient by the name of Mrs. Lawry. She looked a
little stressed and I was not here yesterday when the information about her was given. As a result, I offered to go
and help her with what was needed. When I walked in I seen that she was struggling to walk and offered to help
her with getting up as I went to help she hit me in the knee 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).

Was medical treatment provided?  Yes xNo 

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

REPORTER INFORMATION
Individual Submitting Report (print name): Johanna Arana

Signature: Johanna Arana

Date Report Completed: 06/20/2018

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