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 Salma Navarro
Home Address 4040 Flower St Modesto CA
D Student D Employee D Visitor D Vendor
Phone Numbers Home (209) 288-9090 Cell (209)288-9090 Work (209) 555-5555

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes  No
June 23, 2018 12:00 am
Location of Incident
Clinical Health

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 was starting my daily shift, I asked my coworker about the new patients. I then went to check on the patient and I saw her
struggling without a doubt I went to help her out, but she then got bothered and hit me with a cane. I had pain on my left
leg.

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).

I was hurt in the left leg behind my knee.

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) Salma Navarro

Signature: Salma Navarro

Date Report Completed June 24, 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

June 23, 2018 The doctor talked to the nurse and patient Doctor

June 24, 2018 The nurse was directed to be more careful and check the charts with Doctor
cautions
June 25, 2018 The patient was given calming medications. Doctor