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 Briyana Ross
Home Address 2298 Ingleside Drive Macon Ga 31204
D Student x Employee D Visitor D Vendor
Phone Numbers Home 478-798-1238 Cell 478-978-2298 Work 478-741-1956

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes X No
March 23, 2018 11:12
Location of Incident
Beachwood Manor 123 Key St Macon Ga 31206

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 the room to check on the patient and interduce myself. I see that she was struggling trying to get
balance and I offered to help her. She than hit me with her cane in the 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).
Left leg, Bruised

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

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

REPORTER INFORMATION
Individual Submitting Report (print name): Briyana Ross

Signature: Briyana Ross

Date Report Completed: March 23, 2018

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