INDERKUM JR TIGERSINCIDENT REPORT
CONFIDENTIAL • Complete as soon as possible after the incident
1. INCIDENT INFORMATION
Date of incident:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time:
Hour Minutes
AM
PM
AM/PM Option
Location / facility:
Team / sport / division:
Date report completed:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reported by / role:
First Name
Last Name
Incident type (check all that apply):
Injury / illness
Accident
Behavior / misconduct
Bullying / harassment
Equipment / facility
Safety violation
Parent / spectator concern
Other
2. PEOPLE INVOLVED
2. PEOPLE INVOLVED
Rows
Role: Athlete Coach Volunteer Parent Other
Age / team / division (if applicable):
Other person(s) involved:
Witness name(s) and contact information:
3. DESCRIPTION OF INCIDENT
Describe what happened in chronological order. Include the activity taking place, actions observed, and relevant conditions. Use objective facts; avoid assumptions or conclusions.
4. INJURY / MEDICAL RESPONSE (COMPLETE IF APPLICABLE)
Was anyone injured or became ill?
No
Yes
Body area / symptoms:
Apparent severity:
Minor
Moderate
Serious / urgent
Unknown
First aid provided?
No
Yes
First aid / care provided by:
First Name
Last Name
Time:
Hour Minutes
AM
PM
AM/PM Option
Details:
Emergency services contacted?
No
Yes
Agency:
Time:
Hour Minutes
AM
PM
AM/PM Option
Was the participant removed from activity?
No
Yes
Referred for medical evaluation?
No
Yes
N/A
5. NOTIFICATIONS AND IMMEDIATE ACTIONS
Parent / guardian notified?
No
Yes
N/A
Name notified:
First Name
Last Name
Date / time:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Notified by:
First Name
Last Name
Other persons notified (director / safety lead):
First Name
Last Name
Immediate steps taken to protect participants, secure the area, or address the concern:
INDERKUM JR TIGERS • CONFIDENTIAL PARTICIPANT / INCIDENT RECORD
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INDERKUM JR TIGERS • CONFIDENTIAL PARTICIPANT / INCIDENT RECORD
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INDERKUM JR TIGERSINDERKUM JR TIGERS | INCIDENT REPORT
Continuation and administrative review
6. WITNESS STATEMENTS
List witness names and record their own words when possible. Attach additional signed statements if needed.
7. FOLLOW-UP AND CORRECTIVE ACTION
Further action required:
No
Yes
If yes, describe:
Person responsible for follow-up:
First Name
Last Name
Target date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Follow-up completed on:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Outcome / resolution:
8. ADMINISTRATOR REVIEW
Reviewed by (name / title):
First Name
Last Name
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Review outcome:
Closed
Monitoring required
Referred for additional review
Other
9. ACKNOWLEDGMENT AND SIGNATURES
I certify that this report is accurate and complete to the best of my knowledge. My signature confirms that I completed or reviewed this report; it does not necessarily indicate agreement with every statement.
Person completing report:
First Name
Last Name
Signature:
Coach / staff supervisor:
First Name
Last Name
Signature:
Program administrator:
First Name
Last Name
Signature:
IMPORTANT:
For an emergency, call 911 first and follow applicable emergency action plans. This form does not replace required medical care, mandated reporting, governing-body notifications, or other legal obligations. Submit the completed report promptly to the program administrator and store it securely with access limited to authorized personnel.
INDERKUM JR TIGERS • CONFIDENTIAL PARTICIPANT / INCIDENT RECORD
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