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 Khatherine Pacorsa
Home Address 4834 E. Geary Fresno, CA 93725
D Student  Employee D Visitor D Vendor
Phone Numbers Home Cell (559) 351-7994 Work

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes  No
04/25/2018 12:45pm
Location of Incident
Beachwood Manor, Mrs Larwy’s room, 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)

Dolores Lawry was trying to get out of bed, and I tried to help her up to avoid her from slipping or
falling onto the hard floor. Mrs. Lawry became aggressive and used her wooden walking cane and
violently stuck me in my left knee.

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).

My left knee was struck with a wooden walking cane. My knee is now badly bruised and causing a lot of
excruciating pain.

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) Khatherine Pacorsa
Signature

Date Report Completed 04/25/2018

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

04/25/2018 All employees follow up with patient’s file