Incident Report
This report is to be completed by the Activity Lead (coach, chaperone, etc.)
Type of Incident
*
Injury
Behavior
Other
Level of incident
*
Major Incident
Minor Incident
Coaches Full Name
*
Situation Details
Person's Full Name
*
The person was a
*
Swimmer
Coach
Chaperone
Official/ Volunteer
Other
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Pool Location
*
Location (ie. changeroom, pool deck etc.)
*
Reported by
*
First Name
Last Name
Description of Incident
*
Behaviour
Bullying, property damage, etc.
If Behaviour - Discipline Action Needed?
*
Yes
No
Not Behviour
If Yes, Describe (If no, type N/A)
*
Physical Injury
If Injury - First Aid Given?
*
Yes
No
Refused
No physical injury
If Yes, Describe (If no, type N/A)
*
EMS/ 911 Called?
*
Yes
No
Was there significant impact to the head, neck, face or body?
*
Yes
No
Witness?
*
Yes
No
Name of Witness
Follow up action to be taken after incident.
*
Office Informed
Head Coach Informed
Facility Notified (If needed)
Parent(s) Notified
No action needed
NYAC Staff Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
INCIDENT REPORT
875 Morningside Ave, Suite 2032. Toronto, Ontario M1C 0C7 Phone: 416-283-8894, Email: info@nyacswimming.ca
Submit
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