Incident Report
Use form for all incidents
When an incident occurs, please complete form immediately. Please TYPE directly in this form and provide as much detail and
information as possible. Even if no injury was sustained or claim was filed, this form must be completed in full and sent to the
[email protected] the National Service Center.
Type of Incident:
Student Injury
Auto Incident
Abuse/Suspected Abuse
Who to notify:
Employee/Volunteer Injury
Employee/Volunteer Misconduct
Youth to Youth Sexual Activity/Abuse
Risk Management Department
National Field Director
Suspected abuse anonymous reporting number 866-607-SAFE (24hrs a day-7 days a week)
Name of person(s) involved in the incident
Jacob Miller
Chapter Executive Director
Where did incident occur? (Physical Address Location)
Centreville Elementary School-Elementary Commons
Centreville, MI
Did an injury occur? Yes
No
Was medical attention required? Yes
No
Is injured person
Employee
Youth Volunteer
Date of Incident
Time of Incident
7:15 AM
PM
If an employee, was this a regular function of the employee’s position?
If not, explain.N/A
Time Employee began work?
N/A AM
PM
Did Employee leave work due to the incident? Yes
No
Did Employee return to work? Yes
No
Name and Address of Doctor or Hospital where injured person was treated
Date:
Time:
12/16/2013
AM
Employee Date of Hire
N/A
PM
Date Reported to you (person filling out this form)
N/A
Name(s) of individuals that may have witnessed the incident (providecontact information if known)
Unknown
Was there property damage? Yes
No
If yes, Who owns the damaged property?
What was damaged?
If there was an injury, what body part was hurt?
(if vehicle please see below)
What was happening just before the incident occurred?Describe the activity, as well as the tools, equipment or material the individual was using. Be specific. Examples: “climbing a
ladder to change light bulb”; “playing basketball in gymnasium”; “daily computer data entry”.
Students were playing an organized basketball game in a carpeted gym like building called the Elementary Commons.
What happened?Tell us how the incident occurred.
Student was playing basketball when he caught the basketball wronng and it bent his finger backwards. He told person in charge and she went and got a bag of vegetables in the
teachers break room (It was all that was available) for the student. He continued to play like usual after icing for about 5 minutes. He didn't make a big deal of it and didn't seem to
need more medical attention after that. Parents didn't report anything to YFC nor did they say anything to person in charge. Students mentioned all information in passing on 1/7/2014
in response to a question if anything interesting happened during Spring Break. He didn't bring it up again. Parents still have not mentioned anything.
Were the proper authorities contacted?Yes
Contact Person: Sarah Atkins
No
If so, report #:
Phone #: 269-689-7395
Is there a contact person with the authorities? Yes
No
Email address: [email protected]
Who else has been contacted?(please include their contact information) No one.
Has the NSC been notified? Yes
No
Date
Additional notes or other relevant information if needed:
N/A
Vehicles involved? Please list the following for each vehicle in the incident:
Vehicle #1 (YFC vehicle) Year:
Make:
Model:
VIN#:
License Plate # & State:
Driver Name:
Vehicle #2
Year:
Make:
Model:
VIN#:
License Plate # & State:
Driver Name:
Completed by:Sarah AtkinsContact Phone: 269-689-7395
Executive Director:Ken MillsContact Phone: 269-651-1669
Date form was completed: 02/24/2014
Date: 2/24/2014
Form Date: 2-1-2012