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 Evenly McKnight
Home Address 1234 Lone Wolf
Student Employee Visitor Vendor
Phone Numbers Home (915)1234567 Cell (915)4567890 Work (915)9631234

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified Yes No
Oct 12, 2000 3:00pm

Location of Incident
2345 Oncology Fremont, Nebraska

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Evanly Mcknight on October 12, 2000 was diagnosed with breast cancer and went to an Oncology Clinic at
Fremont, Nebraska to undergo chemothearpy. In less then a year she had recurrence the breast cancer and with the
second go of chemothearpy she had found out she was infected with Hepatits C virus. 99 patients were infected with
Hepatitis C at that same Oncolog. They had reused syringes and misuse of medication vials.

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, the onoclogy resued the syringe and misues the mediaction vials which cause Evanly McKnight to contrcated
Hepatits C.

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) Michelle Franco

Signature

Date Report Completed

8/12/01

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