Y - Report

Member/Guest InjuryOn the Clock Staff InjuryCode of Conduct ViolationRed Flag (Suspected Abuse and/or personnel policy violation)Near Miss (an accident almost happened, but did not)Other

Please note that 'On the Clock Staff Injury' should only be selected if the individual was clocked in and working. If the staff member was not working at the time of injury, the incident should be recorded as 'Member/Guest Injury.' Thank you!

YMCA BranchYMCA Camp CherokeeYMCA Afterschool Site

YMCA Afterschool/Camp/Sports/SwimThird Party Camp/Class/SportThis incident did not occur during programing

Hour Minutes

AM/PM Option

Yes, minors were involvedYes, adults were involvedYes, minors and adults were involvedNo

Told verbally at CheckoutPhone Call/EmailSigned Injury ReportParent saw the incident

Yes, both were called.Police were called.EMS was called.Neither were called.

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.

Statement from AccuserStatement from AccusedStatement from Y StaffStatement from Witnesses (3 minimum)Video Capture (if available)*Copy of Police Report (if available)*Discussion with 3+ Safety Committee Members

YMCA Report Form