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  • YMCA Report Form

  • Is the person filing this report a YMCA Staff Member?
  • What type of incident are you reporting?*

  • 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! 

  • Did this event happen at a branch, camp or offsite?*
  • Which branch?*
  • Which afterschool site?*
  • In which area did the incident occur?
  • In which area did the incident occur?
  • Did this incident occur during Programming?
  • Date of incident:
     - -
  • Date of Birth (if available)
     - -
  • Was a minor involved in this incident?
  • Were any other people involved in this incident?
  • Did a lifeguard perform a water rescue?
  • Please select any Member Code of Conduct violations that occurred:
  • Was the Member Misconduct noted in CORE?
  • Communication with Parent (Check any that apply - if none apply, leave blank):
  • YMCA Staff are mandated reporters. Have you reported the possible abuse to DSS (1-888-227-3487)?
  • Did the staff member finish their shift?
  • Did the incident require additional medical attention (from EMS or a Doctor)?
  • Were the police and/or EMS called for this incident?
  • Date of incident:
     - -

  • 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. 

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    • Follow Up Action (Completed after Incident Report is Submitted)  

    • *This Y report has been emailed to the CEO, CHRO, Director of Human Resources, VP of Training, Director of Association Operations, VP of Childcare and the Branch Director/Branch VP. All of those individuals have Praesidium Guardianship Certification. If the incident requires an investigation or immediate action is needed, at least three of the above individuals will discuss how to proceed. 

    • Does this incident/allegation need to be investigated by the Y?
    • Has the accused been made aware and removed from the Y programing during the investigation?
    • Has the victim/family been made aware of the accusation and informed of the investigation process?
    • Investigation (all should be checked):
    • Have the accuser and accused been made aware of the outcomes?
    • Should be Empty: