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 Jessica Coe
Home Address 2300 Jackson Street Greensboro,NC 27401
D Student x Employee D Visitor D Vendor
Phone Home (336) 841-1234 Cell (336)841-2424 Work (336)555-5555
d8(9999nhxNumbers(
336)680-1021
INFORMATION ABOUT THE INCIDENT
Date of Incident 6/20/2018 Time 03:35 Pm Police Notified  Yes X No

Location of Incident
Patient’s room 106A , right side of patient’s bed.

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Every day prior to my shift I obtain necessary information from the supervisor or previous nurse tech before care . I ,Jessica
Coe, Nurse tech 1 , walked in to introduce myself to Mrs. Lawry ,whom is a new admit to our facility, as her nurse Tech for
the day. Mrs. Lawry was trying to stand and looked as if she was at risk to fall when I arrived. I rushed over quickly to assist
Mrs. Lawry to sit in her bed. Mrs. Lawry yelled she didn’t need my assistance and struck me with her walking cane. I left the
room in pain and notified my supervisor immediately.

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). I have a bruise on my lower right leg , with no cuts or laceration.

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)
Jessica Coe
Signature
Jessica Coe
Date Report Completed
6/30/2018

FOR OFFICE USE ONLY

Report Received by Melissa Ross D.O.N. Date 6/30/2018 _

 FOR OFFICE USE ONLY

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

Date Action Taken By Whom

7/1/2018 Meeting with supervisor ,injured nurse tech and D.O.N. Melissa Ross D.O.N.

7/1/2018 Patient’s Chart updated Melissa Ross D.O.N.

7/1/2018 Family notified Melissa Ross D.O.N.

7/1/2018 Written warning to the supervisor on duty for lack of information given Melissa Ross D.O.N.
to care provider