YMCA of Metro Atlanta Incident Reporting

YMCA of Metro Atlanta Incident Reporting

For Internal Use Only
What type of Incident are you reporting?*

Youth and Teen Safety Policy ReportIncident Report
Youth and Teen Safety Policy Report Examples:
- Allegations of Abuse (physical, verbal, sexual, mental, neglect)
- Red-Flag or Inappropriate behavior
- Consumer-to-consumer sexual behavior
- Any violation of the Youth and Teen Safety Policy
Incident Report Examples:
- Administration of First-Aid/CPR
- Member behavior/injury
- Property damage/theft
- Vehicular incident
Youth and Teen Safety Policy Report

For Internal use only
Please complete the form as accurately as possible. Fields with RED * are required fields.

REPORTING DETAILS:

DATE: Date that this report is being completed

DATE/TIME OF OCCURENCE: Date and Time when alleged violation occurred

FORM COMPLETED BY: Y Staff who is reporting the alleged violation

LOCATION NAME: Enter the location where the alleged violation occurred

TYPE OF INCIDENT: Select the Incident Type from the dropdown selection

DESCRIBE EXACTLY WHAT HAPPENED: Enter a detailed summary of the event that occurred

Review for completeness and submit.
Date:*

MonthDayYear
Date
Date of Occurence:*

MonthDayYear
Date
Time of Occurrence:*

Hour Minutes

AM/PM Option
Form Completed By:*
First & Last Name
Location Name:*
Offsite Location:
Example: Afterschool Site, Sports Fields, etc.
What area of the location did the alleged violation occur in?*
Example: Locker room, Wellness Area, Track, etc.
Name of Person Involved:*
First & Last Name
Age:*
(Name of Parent/Guardian if Under 18):
First & Last Name
Contact Information:*
Phone Number/Email Address
Contact ID:
Type of Incident:*
Type of Abuse:
Describe Exactly What Happened:*
Describe the Response:*

Behavior InterruptedSeparated/Protected YouthIncrease SupervisionOther
Name/Role of Individual(s) Reporting:*
Name/Role of Witness(es):
Witness Contact Information:
Email/Phone Number
Please describe any action taken by staff in response to this incident, who has been informed of the incident, and is further support needed from the Youth and Teen Safety Leadership team:
Has this alleged incident been reported to Human Resources through HRConfidential@ymcaatl.zendesk.com?

YesNo
Has this alleged incident been reported to appropriate authorities based on mandatory reporting requirements (DFCS, BFTS, etc.)?

YesNo
If Yes, please list the name of organization(s) reported to and any case numbers provided:
Upload any supporting Photos/Documents here:

Cancelof
YMCA of Metro Atlanta Incident Report

For internal use only
Please complete the form as accurately as possible. Fields with RED * are required fields.

REPORTING DETAILS:

DATE: Date that this report is being completed

DATE/TIME OF OCCURENCE: Date and Time when incident occurred

FORM COMPLETED BY: Y Staff who is reporting the incident

LOCATION NAME: Enter the location for the incident

TYPE OF INCIDENT: Select the Incident Type from the dropdown selection

DESCRIBE EXACTLY WHAT HAPPENED: Enter a detailed summary of the event that occurred

Review for completeness and submit.
Date:*

MonthDayYear
Date
Date of Occurence:*

MonthDayYear
Date
Time of Occurrence:*

Hour Minutes

AM/PM Option
Form Completed By:*
Location Name:*
Offsite Location:
Example: Afterschool site, Sports fields, etc.
Name of Person Affected:*
First & Last Name
Age:*
Name of Parent/Guardian (if under 18):
First & Last Name
Contact Information:*
Phone Number/Email Address
Contact ID:
What Program or Activity was the Person Participating in?
Example: Group Ex class, Swimming, etc.
What Program or Activity was the Person Participating in?*
Type of Incident:*
Describe Exactly What Happened:*
What Assistance was given at the Scene:*
Persons Giving Assistance:*
Name & Phone Number
Where was person taken after incident? (Name of doctor, hospital, resumed activity, released to parent, etc.)*
Witness(es):
FIrst & Last Name
Witness Contact Information:
Email/Phone Number
Upload any supporting Photos/Documents here:

Cancelof
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YMCA of Metro Atlanta Incident Reporting

Youth and Teen Safety Policy Report

YMCA of Metro Atlanta Incident Report