MIRF REPORT
Request:
Medical
Campus:
San Marcos/Escondido
Location/Building:
[68]
Date of Incident:
October 8, 2019
Time of Incident:
9:15 PM
Number of Patients for this Incident:
[75]
List Patient(s) Name, Age, Parent/Guardian (if under 18),… :
Cortlyn Cusey (age 12)
Ben Cusey Phone #858-472-8130
Caitlin Cusey Phone #
Describe Medical Event:
Child fell off of a skate board while skateboarding after Elevate Jr. High group and broke her arm. Dad was present when it occurred and immediately transported her to Palomar Hospital. Safety found out after the incident. Family are regular members and seemed ok with the incident other than being concerned for their daughter.
Actions Taken by Team Members:
[79]
Number of NCSM Team Members Involved:
[81]
List Name(s) of NCSM Team Members Involved:
Bill Weese submitting report for Jr. High Pastor TJ Brooks who followed up with the parents n the following days.
Was medical attention accepted?”:
No
Medical attention was refused by (name and relationship to… :
Was 911 emergency service called?:
No
Was patient transported via 911 emergency services?:
No
What hospital was victim transported to?:
Palomar
NCS team lead:
[249]
If any revisions or updates are needed to be made to this incident, complete the form below.
Please select a valid form