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 Luisa Cordova Sotelo
Home Address 20655 Hiappo Rd.
D Student D Employee D Visitor D Vendor
Phone Numbers Home (209)891-0111 Cell (831)123-4567 Work (545)980-9876

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes  No
06/23/18 11:08 am
Location of Incident
Sharp Memorial Hospital, Patient room #210
Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Medical Assistant went to check on Mrs. Lawry in room #210. MA entered Mrs. Lawry’s room and saw
her struggling and asked if the patient needed help, the patient was sitting on the bed and became
aggressive. When the MA tried to help Mrs. Lawry, she became violent and hit the MA on the left
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).
Yes, Medical Assistant was hit across the left knee resulting in a bruise.

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

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

REPORTER INFORMATION
Individual Submitting Report (print name) Luisa Cordova Sotelo

Signature Luisa Cordova Sotelo

Date Report Completed 06/23/18

FOR OFFICE USE ONLY

Report Received by Luisa Cordova Sotelo Date 06/23/18

 FOR OFFICE USE ONLY

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

Date Action Taken By Whom

6/27/18 Take M.A. back to training; speak to her about the steps she should Luisa Cordova Sotelo
have taken to avoid this
6/27/18 Go over patient’s chart to look for potential ways of preventing this Luisa Cordova Sotelo
from occurring again.
6/27/18 Talk to patient’s family to help make her feel more comfortable and Luisa Cordova Sotelo
figure out any accommodations necessary.
6/28/18 Talk to staff and warn them about the patient. As well as reminding Luisa Cordova Sotelo
them to carefully check their patient’s charts before engaging with
them.
6/28/18 Make sure to observe patient’s behavior looking for anything which Luisa Cordova Sotelo
causes her to become aggressive.
6/29/18 Look at additional information from past doctors and medical clinics Luisa Cordova Sotelo