SAMPLE INCIDENT REPORT

DATE OF INCIDENT: 1:30 to 2:30 a.m., XXXXXX LOCATION OF INCIDENT: XXXXXXX DATE SUBMITTED: XXXXXX SUBMITTED BY: Mark Barneche, Assistant Director SUBMITTED TO: Ezra Plank, Director

RE: Jane Smith (900327276230)

Description of incident: During the early morning hours of January 23rd, Jane Smith went to Club D with Taylor Swift, Selena Gomez, and Nicky Minaj and drank alcohol to the point of extreme intoxication. (reportedly ½ bottle of vodka) During the course of the evening, Taylor, Selena, and Nicky, the staff at Club D called a taxi to assist Jane home after she began showing signs of nausea and vomiting. The taxi delivered the students to Clinic Cecil, where the group decided to exit the taxi with Jane for fear that she was going to vomit. At 1:25 a.m., I received a call on my cell phone from Nicky saying that she had gone out with Jane and that she was “not doing well” and that “we can’t get her home”. Upon arriving on the scene, I found the group huddled on the ground near Jane, who was seated on the pavement, in the driveway of Clinic Cecil near Av. Marc-Dufour. Upon arriving, I performed a basic physical examination. Though she smelled of alcohol and vomit and was clearly intoxicated, Jane could respond to questions, her pupils dialated normally, she exhibited normal skin coloring, and her pulse was normal. Initially, Jane could not be compelled to stand up and return back to the house. She was crying, saying she was “scared”, that she wanted to be a “good person but was not”, that she “regrets everything”, that she “did not want to get in trouble”, that she “did not want to die” or be “raped”. She mentioned that she had not drank enough to be drunk so she suspected her drink was drugged, an allegation that the group emphatically denied since they reported they were with her all evening. She also alleged that someone had “shot her with something in the bathroom”, which the group again denied saying they had been with her in the bathroom and reported no such incident.

After 10-15 minutes of attempting to persuade Jane to try to walk back to Maison du Lac, I told her I was going to be forced to call the police out of concern for her safety. She initially would not go because she feared she would be “kicked out of the program” if she went inside the house. I assured her she would not be in trouble and that getting her in the house was the only way for her to be safe. With the assistance of Taylor and Nicky, we managed stand Jane on her feet and walk 5 minutes to Maison du Lac and into the house. She could not walk or stand on her own.

Once inside the house, we took Jane to her room where she proceeded to throw up again. I established the details of the evening with Selena Gomez. After confirming the amount of alcohol drunk and inquiring about recreational drugs or the possibility of being drugged with Selena in the hallway, I instructed Taylor and Nicky to stay with Jane, assist her in drinking some water, and to gradually move her into her bed. Jane continued to express concern for “Justin” and made repeated comments regarding cancer, Justin’s death, or own death and that “she was not ready”. I encouraged them to wake me again if Jane’s comments, particularly dealing with fear and disappointment, did not subside. At 2:30 a.m. I left Jane under their supervision, wrote this report, and returned to bed.