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 Cierra Patillo
Home Address 36 First Avenue Atlanta, Ga
D Student DI’m the Employee D Visitor D Vendor
Phone Numbers Home Cell Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes  No
9/17/2018 9:00 am No police
Location of Incident involved
Nursing Home

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
While helping the patient get off of the bed, she became very aggressive and swung her cane and it me in the side of the
left knee.

Were there any witnesses to the incident?  Yes  No, there wasn’t any witnesses.
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).
The patient was not injured.

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

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

REPORTER INFORMATION
Individual Submitting Report (print name) Cierra Patillo

Signature Cierra Patillo

Date Report Completed 9/17/18

FOR OFFICE USE ONLY

Report Received by Donna Date 9/17/18 _

 FOR OFFICE USE ONLY

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

Date Action Taken By Whom

Donna should have told the day shift nurses about the patient’s behavior.

Donna could’ve introduced the patient to the new nurse.

Document the patient’s behavior.

Reassure the patient that she is in good hands.