Accident/Incident Report Form

Accident/Incident Report Form

Please fill out this form to report any accidents or incidents that occur within the organization. Providing detailed information helps us ensure safety and proper follow-up.
Your Full Name*

First NameLast Name
Your YMCA Email (if you have one)
example@example.com
Your Supervisor or Department Email:*
Your Contact Phone Number
Please enter a valid phone number.
Date of Incident*

MonthDayYear
Date
Time of Incident*

Hour Minutes

AM/PM Option
Name, age and contact information of person involved*
Location*

Main Y GymMain Y Cardio / WeightMain Y Climbing WallMain Y Parking lotMain Y OtherChild WatchAfter School Program (list which site in description below)Off Site Program (list which site in description below)
For after-school sites, choose the site email
Location Detail (where in the building)*
Description of the Incident (please provide detailed account)*
People Involved including any witnesses*
Injuries Sustained (if any)
Actions Taken - Indicate whether the person was taken to the Doctor or hospital.
Name of Supervisor Contacted, Time of Contact and comments if any*
Additional Comments or Details
Attach Photos or Documents (optional)

Cancelof
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