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    Incident Report

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    This incident report form summarizes an incident involving Dakota Cloud that occurred on November 27, 2017 at 15:15 in Beachwood Manor Room 313. Dakota entered Mrs. Lawry's room to offer help getting out of bed but was hollered at and hit on the left knee, causing a 4-inch laceration and deep bruise. Dakota received treatment at an urgent care for the injury. The completed form was submitted to the President's Office within 24 hours as required.

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    Incident Report

    Uploaded by

    api-385223660
    871 views2 pages
    This incident report form summarizes an incident involving Dakota Cloud that occurred on November 27, 2017 at 15:15 in Beachwood Manor Room 313. Dakota entered Mrs. Lawry's room to offer help getting out of bed but was hollered at and hit on the left knee, causing a 4-inch laceration and deep bruise. Dakota received treatment at an urgent care for the injury. The completed form was submitted to the President's Office within 24 hours as required.

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    This incident report form summarizes an incident involving Dakota Cloud that occurred on November 27, 2017 at 15:15 in Beachwood Manor Room 313. Dakota entered Mrs. Lawry's room to offer help getting out of bed but was hollered at and hit on the left knee, causing a 4-inch laceration and deep bruise. Dakota received treatment at an urgent care for the injury. The completed form was submitted to the President's Office within 24 hours as required.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    871 views2 pages

    Incident Report

    Uploaded by

    api-385223660
    This incident report form summarizes an incident involving Dakota Cloud that occurred on November 27, 2017 at 15:15 in Beachwood Manor Room 313. Dakota entered Mrs. Lawry's room to offer help getting out of bed but was hollered at and hit on the left knee, causing a 4-inch laceration and deep bruise. Dakota received treatment at an urgent care for the injury. The completed form was submitted to the President's Office within 24 hours as required.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    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 Presidents Office.
    INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT
    Full Name Dakota DeAnn CLoud
    Home Address 1168 Reese Ln Haltom City Texas 76117
    Student X Employee Visitor Vendor
    Phone Numbers Home Cell 817-657-2010 Work 903-345-6345

    INFORMATION ABOUT THE INCIDENT


    Date of Incident 11/27/2017 Time 15:15 Police Notified Yes No

    Location of Incident
    Beachwood Manor 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) I walked into Mrs. Lawrys room to see if she wanted to eat breakfast, once I
    entered her room
    I noticed she was having a tough time getting out of her bed, so I walked over to her to offer to
    help her then she hollered at me for me to let her do it herself then hit me on the outside part of
    my left knee causing a deep muscle bruise and a 4-inch laceration going from my knee down
    to my shin.

    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).

    There is a laceration and deep bruise on outside knee on left leg. The laceration is 4
    long running down toward shin. The deep bruise will heal but needs a brace to keep
    movement to a minimum.

    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) Dakota Cloud

    Signature Dakota Cloud

    Date Report Completed 11/27/2017


    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

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