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 Briana Lopez
Home Address 1534 E. Washington Ave 93725 Fresno, CA
D Student D Employee D Visitor D Vendor
Phone Numbers Home (559) 368-2465 Cell (559) 483-9265 Work Medical Assistant

INFORMATION ABOUT THE INCIDENT

Date of Incident Time Police Notified  Yes X No
6/20/18 8:00am
Location of Incident
Brightwood

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 got to work, and I asked my supervisor how her weekend went, she explained that there was a new patient, Ms. Lawrey.
She explained how she did not get sleep and was a bit aggressive. So, I went to go introduce myself and say good morning.
When I walked in the room, I seen her struggling to get out of her bed, so I offered help. When approaching her to assist
Her, she yelled and hit me in the Knee with her cane.

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).

I was not injured just a bruise and small cut.

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

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

REPORTER INFORMATION
Individual Submitting Report (print name) Briana Lopez

Signature
BrianaLopez
Date Report Completed 6/20/18

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