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 Miyoshi Webb
Home Address 2131 Apple Lane St Greensboro Nc 27410
D Student YES Employee D Visitor D Vendor
Phone Numbers Home 336-254-6325 Cell 336-210-7409 Work 336-832-7000

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified No
06/27/2018 12:35 Pm
Location of Incident
Moses Cone Hospital Room 6East 21

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 walked into patient’s room to assist her because I saw she was struggling to get up off the bed as I was trying to assist her
she hit my back of leg with cane and yelled she wanted to do it herself.

Were there any witnesses to the incident?  Yes X 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).
Bruise on back of leg/swollen

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

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

REPORTER INFORMATION
Individual Submitting Report (print name) Miyoshi Webb

Signature

Date Report Completed 06/27/2018

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

07/01/2018 Try to have the members who care for the patient to stay the same if Supervisor
they memory issues and are aggressive.