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 Presidents Office.
INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT
Full Name Dakota DeAnn CLoud
Home Address 1168 Reese Ln Haltom City Texas 76117
Student X Employee Visitor Vendor
Phone Numbers Home Cell 817-657-2010 Work 903-345-6345

INFORMATION ABOUT THE INCIDENT

Date of Incident 11/27/2017 Time 15:15 Police Notified Yes No

Location of Incident
Beachwood Manor Room 313

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 Mrs. Lawrys room to see if she wanted to eat breakfast, once I
entered her room
I noticed she was having a tough time getting out of her bed, so I walked over to her to offer to
help her then she hollered at me for me to let her do it herself then hit me on the outside part of
my left knee causing a deep muscle bruise and a 4-inch laceration going from my knee down
to my shin.

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 is a laceration and deep bruise on outside knee on left leg. The laceration is 4
long running down toward shin. The deep bruise will heal but needs a brace to keep
movement to a minimum.

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) Dakota Cloud

Signature Dakota Cloud

Date Report Completed 11/27/2017

 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