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    Assg Incidentreportform 20180122 Ah102 K

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    This incident report form documents an incident involving Keyasha Toombs, a student, that occurred on September 18th, 2018 at 5:30 pm at Beachwood Manor. Keyasha offered to help a new patient who was having trouble sitting down, but the patient hit Keyasha on the knee with her cane and insisted on doing it herself. Keyasha was not seriously injured. The report was completed and submitted by Keyasha Toombs on the date of the incident.

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    Assg Incidentreportform 20180122 Ah102 K

    Uploaded by

    api-428074700
    22 views2 pages
    This incident report form documents an incident involving Keyasha Toombs, a student, that occurred on September 18th, 2018 at 5:30 pm at Beachwood Manor. Keyasha offered to help a new patient who was having trouble sitting down, but the patient hit Keyasha on the knee with her cane and insisted on doing it herself. Keyasha was not seriously injured. The report was completed and submitted by Keyasha Toombs on the date of the incident.

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    assg incidentreportform 20180122 ah102 k

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    This incident report form documents an incident involving Keyasha Toombs, a student, that occurred on September 18th, 2018 at 5:30 pm at Beachwood Manor. Keyasha offered to help a new patient who was having trouble sitting down, but the patient hit Keyasha on the knee with her cane and insisted on doing it herself. Keyasha was not seriously injured. The report was completed and submitted by Keyasha Toombs on the date of the incident.

    Copyright:

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

    Assg Incidentreportform 20180122 Ah102 K

    Uploaded by

    api-428074700
    This incident report form documents an incident involving Keyasha Toombs, a student, that occurred on September 18th, 2018 at 5:30 pm at Beachwood Manor. Keyasha offered to help a new patient who was having trouble sitting down, but the patient hit Keyasha on the knee with her cane and insisted on doing it herself. Keyasha was not seriously injured. The report was completed and submitted by Keyasha Toombs on the date of the incident.

    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 President’s Office.

    INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT


    Full Name Keyasha Toombs
    Home Address 1022 chestnut ave.
    D Student D Employee D Visitor D Vendor
    Phone Numbers Home Cell 7065932156 Work

    INFORMATION ABOUT THE INCIDENT


    Date of Incident Time Police Notified  Yes  No
    9/18/18 5:30 pm
    Location of Incident
    Beachwood manor

    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 in the room to introduce myself to the new patient and I noticed she was having trouble sitting down. I offered to
    help her out and she hit me on the knee with her cane and insisted I let her do it herself.

    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).

    No, I wasn’t seriously injured.

    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)
    Keyasha toombs
    Signature
    Keyasha Toombs
    Date Report Completed
    9/18/18

    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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