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: Skyla Rodgers
Home Address: 1300 N sixth St, Fresno, Ca
D Student X Employee D Visitor D Vendor
Phone Numbers Home Cell Work

INFORMATION ABOUT THE INCIDENT

Date of Incident: 10/17/2018 Time: 8:00 am Police Notified  Yes X No

Location of Incident: Graceful Manor Center (2145 east Wishon road Clovis, Ca 93612)
Patient’s room in 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):

Went to assist patient in getting up to have breakfast. As I was assisting patient on getting up out of her bed
to stand and walk the patient got very aggressive and etchy. She refused my assistance and hit me in my knee
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).
Patient had No injuries.

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

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

REPORTER INFORMATION
Individual Submitting Report (print name): Skyla Rodgers

Signature: Skyla Rodgers

Date Report Completed: 10/18/18

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

10/19/18 Diet plan D.smith
10/22/18 Assessment E.Warren
10/25/18 Meet with daughters to find out likes and dislikes N.Edwards
10/26/18 Assessment M.Warren
10/29/18 Assessment E.Warren

I think a supervisor should identify a potential hazard assess the risk of workers being
injured because of the patient’s behavior as she was very aggressive. Complete routine
admittance procedures and use existing information to determine a hazard does exist and
gather information from various sources to assess the risk based on the information she had
gathered so staff can be cautious and prepared. I believe that putting in place measures
that would minimize the risk the staff’s exposure to violence and alerted the staff as the key
to any safety measure to ensure the information is communicated to all that is at risk. It is
very important to consult with your staff and who ever may be at risk to lower incidents and
to keep everyone at the facility safe.