Incident Reporting Form for YMCAs and YWCAs
Location _______________________________________________ Injured Person __________________________________________
Address _______________________________________________________________ Phone _________________________________
Parent / Guardian _______________________ Address _______________________________________ Phone _________________
Incident Date ___/___/______
Time ___ : ___
Gender
am pm
Male
Female
Age _____
Nursery
Preschool
Elementary
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Middle School
High School
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Young Adult
Adult
Senior
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Status
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Participant □
Day Pass
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Guest □
Other □
Member
Incident Description
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________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Location
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aquatics area
athletic / play field
cabin / tent
campfire / meeting area
challenge course
child watch / babysitting
Program
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aquatics
camp: day / holiday
camp: resident
camp: sports
Activity
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aquatics: boating, all forms
aquatics: exercise class
aquatics: family / free swim
aquatics: lap swim
aquatics: lessons
aquatics: team
baseball / softball / t-ball
basketball
bicycles / motorbikes
Specific Action
□ aggressive behavior of / by
□ caught in, by, or between
□ contact with / exposure to
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childcare area
class / meeting room
climbing wall / tower
ex. rm: aerobics, etc.
ex. rm: cardio / strength equip
ex. rm: free weights
gym
gymnastics facility
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lobby / halls / stairs
locker / rest room
parking lot / garage
play structure or area: interior
playground
racquetball court
range: rifle / archery
residence facility
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childcare: before & after
childcare: child watch
childcare: outdoor education
childcare: preschool / daycare
health & fitness: organized
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health & fitness: personal
non-sport activities
senior program / activity
social outreach
special events / field trips
□ sports: adult
□ sports: informal
□ sports: youth
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class: aerobics
class: kick-boxing
class: martial arts
dance
dressing / undressing
exercise: cardio equipment
exercise: free weights
exercise: strength equipment
exercise: run / walk
exercise: other personal
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football
free / unstructured play
games / structured activity
gymnastics
hiking / backpacking
hockey (ice or roller)
horseback riding
playground equipment
racquetball / squash
skateboarding
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exertion
fall (from, onto, into)
handle / use/ touch
horseplay
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inappropriate touch
inhale / ingest
participation / playing
pushed / pulled / bumped
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running track
skating rink
skateboard park
spa / sauna / steam room
stables / horse arena
waterfront (non-pool)
□ other ___________________
□ other ___________________
skating
skiing / snowboarding
soccer
spa / sauna / steambath
theft / robbery
transportation
volleyball / walleyball
walking - incidental
□ other ___________________
struck by / against
verbal attack / taunt / teasing
theft
other ___________________
Medical Treatment / First Aid __________________________________________________
First aid administered?
Yes / No
___________________________________________________________________________
___________________________________________________________________________
Was parent / guardian / emergency contact notified?
Yes / No
By whom: _________________________
If so, when? (date & time) ________________________________
Who was called and what was the outcome? ____________________________________________________________________________
With whom did the injured party leave the site ___________________________________________________________________________
Source of Injury
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aquatics facility: deck / dock
aquatics facility: equipment
aquatics facility: side / bottom
aquatics facility: water
Apparent Injury
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abrasion / scratch
aquatic distress
bite / sting
bloody / hemorrhage
breathe shortened / impaired
Body Part
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arm
hand / finger
wrist
elbow
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Witnesses
leg
foot / toe
ankle
knee
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blood / body fluids
door
environment (sun, heat, etc.)
equipment: exercise
equipment: playground
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floor / ground
furniture
insect / animal
locker / cabinet
object (ball, bat, toy, etc.)
□ person (another)
□ self
□ wall / vertical surface
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bruise / contusion
burn / blister
cramp
cut / puncture
dislocation
dizziness / unconscious
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fear / intimidation
fracture / break
irritation / reaction
jam
pain / soreness
pinch / crush
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□ other ___________________
seizure / dysfunction
sprain / strain
vomiting
no visible / apparent injury
□ other ___________________
Circle if

applicable
( right )
( left )
( upper )
( lower )
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shoulder
chest
stomach
side
back
buttocks
hip
groin
face
ear
eye
nose
head
neck
heart
lungs
mouth / lips
mind / psyche
none
___________
(check box to indicate staff [s], participant [p], or volunteer [v]; indicate age for youthful witnesses)
spv
Name*
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_____________________________________________________________________________________________________
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_____________________________________________________________________________________________________
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_____________________________________________________________________________________________________
Follow-Up
Age
Phone*
Was there follow-up contact? □ Yes □ No
Address
City
State
If yes, date and by whom? ________________
Zip
by ___________________
If yes, detail status. ____________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Comments
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Staff Name ________________________________
Position ___________________________
Date ___________________
Staff Signature _____________________________
Exec Signature ______________________
Date ___________________