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: Mary Brown
Home Address: 2010 Narchey Rd Charlotte NC 28212
D Student D Employee D Visitor D Vendor
Phone Numbers Home Cell Work

INFORMATION ABOUT THE INCIDENT

Date of Incident05/30/2018 Time: 1:00pm Police Notified  Yes No

Location of Incident: Ms.Lawry room

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)

The staff entered the room and greeted the resident and decided to help the resident and the resident was very aggressive
And hit the staff on her leg. The nurse should have giving more detail about the resident by going over the plan with the
staff. The supervisor should always go through the assessment hazards with the staff.

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).
The staff got injured on her left leg but she used some pain ointment by applying it on her leg.

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) GRACE MASSABOI

Signature, GMassaboi

Date Report Completed: 05/30/2018

FOR OFFICE USE ONLY

Report Received by: Grace Massaboi Date: 05/30/2018 _

 FOR OFFICE USE ONLY

Document any follow-up action taken after receipt of the incident report.

Date Action Taken By Whom

05/30/2018 The nurse was advise to go through the plan with the staff. Grace Massaboi

And later did that at the beginning of every admission