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    Anais Luna Mrs

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    1) An incident report form is used to document accidents, injuries, medical situations, or behavior incidents involving students or employees. Crimes or traffic incidents should be directly reported to Campus Public Safety. 2) The report involves an incident on April 22, 2018 at 12:35pm at Beachwood Manner where a resident aggressively hit nurse Anais Luna on the left leg with a cane as she was trying to help the resident out of bed. 3) Nurse Luna's left leg was injured but she did not receive medical treatment for the injury from the hit.

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    Anais Luna Mrs

    Uploaded by

    api-404663715
    52 views2 pages
    1) An incident report form is used to document accidents, injuries, medical situations, or behavior incidents involving students or employees. Crimes or traffic incidents should be directly reported to Campus Public Safety. 2) The report involves an incident on April 22, 2018 at 12:35pm at Beachwood Manner where a resident aggressively hit nurse Anais Luna on the left leg with a cane as she was trying to help the resident out of bed. 3) Nurse Luna's left leg was injured but she did not receive medical treatment for the injury from the hit.

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    anais luna mrs

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    1) An incident report form is used to document accidents, injuries, medical situations, or behavior incidents involving students or employees. Crimes or traffic incidents should be directly reported to Campus Public Safety. 2) The report involves an incident on April 22, 2018 at 12:35pm at Beachwood Manner where a resident aggressively hit nurse Anais Luna on the left leg with a cane as she was trying to help the resident out of bed. 3) Nurse Luna's left leg was injured but she did not receive medical treatment for the injury from the hit.

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

    Anais Luna Mrs

    Uploaded by

    api-404663715
    1) An incident report form is used to document accidents, injuries, medical situations, or behavior incidents involving students or employees. Crimes or traffic incidents should be directly reported to Campus Public Safety. 2) The report involves an incident on April 22, 2018 at 12:35pm at Beachwood Manner where a resident aggressively hit nurse Anais Luna on the left leg with a cane as she was trying to help the resident out of bed. 3) Nurse Luna's left leg was injured but she did not receive medical treatment for the injury from the hit.

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    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 Anais Luna
    Home Address 1211 Nevada Ave
    D Student x Employee D Visitor D Vendor
    Phone Numbers Home (209) 987-3253 Cell (209) 586-2409 Work (209) 555-3000

    INFORMATION ABOUT THE INCIDENT


    Date of Incident Time Police Notified X Yes  No
    04/22/18 12:35pm
    Location of Incident
    Beachwood Manner

    Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
    (attached additional sheets if necessary)
    Residents was struggling to get out of bed , I then insisted on helping patient get out of bed and patient aggressively hit
    nurse the side of her left leg.

    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).
    Body part injured in the incident was my left leg , the leg injured was hit by a cane .

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


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

    REPORTER INFORMATION
    Individual Submitting Report (print name) Anais Luna

    Signature

    Date Report Completed 04/22/18

    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

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