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: Samantha Golen
Home Address: 123 Jones Ave Jasksonville, FL 32212
D Student X Employee D Visitor D Vendor
Phone Numbers Home Cell: 904-266-1399 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes xNo
September 19,2018 2:15pm
Location of Incident
BeachWood Manor

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 went into Mrs. Lawry’s room to see if she would like to get up and have some breakfast. When I arrived in the residents
room she was barefoot and trying to stand using her cane. She looked very shaky, so I tried to assist her. She got agitated
and smacked me in the leg with her cane

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).
Hit in the knee with a cane.

Was medical treatment provided?  Yes xNo 

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

REPORTER INFORMATION
Individual Submitting Report (print name) Samantha Golen

Signature Samantha Golen

Date Report Completed 9-19-2018

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

9-19-2018 Order more frequent checks on Mrs. Lawry and continue documenting
her moods.
9-18-2018 Put in safety measure that no more of the staff members are harmed.

9-18-2018 Info all staff that the resident do have aggressive trendies and for
them to act accordingly
9-18-2018 If incidents keep occurring after resident is settled move towards
having a meeting with her family. Propose the possible options of
placing her in a more secure dementia unit.
9-18-2018 Allow the patient her space and ability to do the thing she can for
herself. With in reason.