Incident Report

Incident Report

All member incidents must be reported within 24 hours. Critical incidents must be reported same day.
Incident Information
Location/Site:*
Incident Date & Time:*

MonthDayYear
Date
Hour MinutesAM/PM Option
External Emergency Services Activated?*

911 (Call, Text, Panic Button)CPS (Child Abuse Reporting)CAT (Centralized Assessment Team)Fire DepartmentPoison ControlPolice Department (Non-Emergency Line)Internally Handled (within GGUSD)Internally Handled (within BGCGG)
Type of Incident: (select more than one, if necessary)*

Behavioral (Injury Included)Behavioral (Severe or Reoccurring)Bladder or Bowel Control (Restroom Accident)Child Abuse or NeglectDamage or Vandalism to Property/ItemsDiversity, Equity & Inclusion (Slur, Joke, Harassment, etc.)Drugs or Alcohol (Suspicion, Reference, or Paraphernalia on Site)Emergency Protocol (Secure, Lockdown, Shelter or Evacuate)IllnessInjury (Minor - Cut, Bruise, Bump, etc.)Injury (Moderate - Head Injury, Extra Monitoring, etc.)Injury (Severe - Medical Emergency)Missing Member (Location Known - Run Away from Group/Unapproved Pick Up)Missing Member (Location Unknown)Parent/Faculty InteractionStranger InteractionSexual Behavior (Touching Private Area - Over Clothes)Sexual Behavior (Touching Private Area - Under Clothes)Sexual Behavior (Exposure of Private Parts)Sexual Behavior (Comment, Joke, Action, Innuendo, Picture, Video, Kiss, etc.)Suicidal Ideation and/or Self HarmThreat (Gun/Weapon Violence, Hurting Others)
Select Critical Level:*
Was this a site wide event?
Member/Staff Information
Member Information*

First NameLast Name
Grade*
Does the member have an intellectual or developmental disability?

YesNo
Were multiple members involved?

YesNo
Member 2 Information

First NameLast Name
Member 2 Grade Level
Member 3 Information

First NameLast Name
Member 3 Grade Level
Member 4 Information

First NameLast Name
Member 4 Grade Level
Member 5 Information

First NameLast Name
Member 5 Grade Level
Staff Reporting:*

First NameLast Name
Other Staff Witnesses:
Incident Details
Location of Where Incident Occurred:*
Incident Occurred During Which Program Piece:
Describe the Incident (be specific, who what where when):*
Did a head injury occur?*

YesNo
It is required that a concussion test is conducted with the member(s), parent notified and sent home with a Head Injury Notification Form. Please indicate these steps have been taken below and upload a scan/picture of the form to this incident report for records.*

YesNo
Was First Aid Given?*

YesNo
First Aid Consisted Of:
Required if First Aid was given. Please indicate if a Head Injury Form was sent home with parent.
Parent/Guardian Information
Was Parent/Guardian of the Member Notified?*

YesNoSite Wide Event - All Notified
Parent/Guardian Name

First NameLast Name
Parent/Guardian Notification Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Were other Parents or Guardians Notified?

YesNo
Parent/Guardian 2 Name

First NameLast Name
2 - Notification Date

MonthDayYear
Date
Parent/Guardian 3 Name

First NameLast Name
3 - Notification Date

MonthDayYear
Date
Parent/Guardian 4 Name

First NameLast Name
4 - Notification Date

MonthDayYear
Date
Parent/Guardian 5 Name

First NameLast Name
5 - Notification Date

MonthDayYear
Date
Notes from Parent/Guardian:
Optional, but encouraged.
Incident Status & Follow Up
Incident Status:*

Pending: Follow Up NeededFully Resolved: Incident Closed
What follow up is needed?
Child Abuse Report Information (Social Worker Name, Case Number, Details of Call)
The following have been notified of the incident (Check all that apply):*

No additional notification necessaryDirect Supervisor or ManagerArea or Site DirectorSchool PrincipalSchool Faculty (Teachers, Custodians)Executive Team MemberSafety & Operations ManagerSuicidal Ideation: Vanessa Leong or CHSRequest for Behavioral Support Specialist Team
Upload any pictures or relevant documents:

Optional - multiple files can be uploaded.
Cancelof
After Submission Follow Up

Insert any updates of the incident here - include date & initials!
Incident Updates:
BGCA Critical Incident

Yes (Submitted Report)No (Deemed Behavioral)
BGCA Critical Incident Updates:
Should be Empty:

Incident Report

Incident Information

Member/Staff Information

Incident Details

Parent/Guardian Information

Incident Status & Follow Up

After Submission Follow Up