YMCA Guest/Staff/Red Flag/Near Miss Incident Form

YMCA Incident Report Form
Are you a YMCA Staff Member?*

YesNo

If you would like follow up about this incident, please list your name and contact information below:
What type of incident are you reporting?*

Member/Guest InjuryStaff InjuryCode of Conduct ViolationRed Flag (Suspected Abuse and/or personnel policy violation)Near Miss (an accident almost happened, but did not)Other
Did this event happen at a branch, camp or offsite?*

YMCA BranchYMCA Camp CherokeeYMCA Afterschool SiteOther
Which branch?*

Baxter Close YMCACharlotte Avenue YMCAClover YMCACSD Community YMCAFort Mill YMCA at the ComplexGregory Family YMCAIndian Land YMCARiverwalk YMCARock Hill Aquatics CenterYMCA Wellness CenterMarion Boan YMCAYork YMCAAssociation Resource Office
Which afterschool site?*

Oakridge ElementaryCrowders Creek ElementaryBethel ElementaryGriggs Road ElementaryLarne ElementaryKinard Elementary
Where did the incident occur?*
In which area did the incident occur?

General Areas (hallways, front desk, meeting rooms, etc.)Locker RoomsChildcare SpacesGym/Track/Racquet BallFitness Areas/Group X Room/Yoga/Etc.AquaticsOther
In which area did the incident occur?

Mess HallLodgeCabinShower House/RestroomWater FrontArcheryArts and CraftsGA FieldOther
Did this incident occur during Programming?

YMCA Afterschool/Camp/Sports/SwimThird Party Camp/Class/SportThis incident did not occur during programing
Please select any Member Code of Conduct violations that occurred:

Inappropriate attireInappropriate footwearHostile or Vulgar LanguagePhysical ContactSexual Activity or ContactHarassment or IntimidationTheft or Destruction of PropertyUsage of Alcohol or Illegal SubstanceUsage of TobaccoLitteringLoiteringPhotography, Video or Audio Recording without YMCA staff approval
Was the Member Misconduct noted in CORE?

YesNo
Date of incident:

MonthDayYear
Date
Time of incident:

Hour Minutes

AM/PM Option
Who is this Incident Report about?

First NameLast Name
Date of Birth (if available)

MonthDayYear
Date
Was a minor involved in this incident?

YesNo
Parent Name (if available)

First NameLast Name
Were any other people involved in this incident?

Yes, minors were involvedYes, adults were involvedYes, minors and adults were involvedNo
Please list any other people that were involved in this incident below:
Describe exactly what happened: *
Communication with Parent (Check any that apply - if none apply, leave blank):

Told verbally at CheckoutPhone Call/EmailSigned Injury ReportParent saw the incident
YMCA Staff are mandated reporters. Have you reported the possible abuse to DSS (1-888-227-3487)?

YesNo
DSS Report Number (if available)
Did the staff member finish their shift?

YesNo
Did the incident require additional medical attention (from EMS or a Doctor)?

YesNoWait and See
Were the police called for this incident?

NoPolice were called, no report was filed.Police were called and a report was filed.Other
Police Report Number (if available)
If this report is for a staff member, they must have been injured while on the clock and the report must be filled out by a different staff member. Permission to Treat Form may be found on the OneDrive under HR.
Staff Member Filing Report*

First NameLast Name
Staff Member Email*
example@example.com
Please upload any relevant photos, videos or other files here. If needed, email them to risk@ymcaup.org.

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YMCA Incident Report Form