Incident Report

Location*
Is the location of the incident a YMCA membership branch location? All childcare, housing, shelter, and off-site locations should select "No".*

YesNo
Level 1 Incidents

Call to 911Police/EMS RespondSevere injury or deathCardiac Arrest (Heart attack)Sexually related incident or allegationAquatics rescueAny form of AbuseProperty Damage that interrupts operationsEvents requiring rescue-breathing, O2 (oxygen), CPR, or AED use
This is a Level 1 Incident.

What to do ALL INCIDENTS (with exception of Aquatics incidents): Call Elissa James: 513-580-THEY (8439), and notify your location's Executive Director.

STAFF INJURIES: In addition to Elissa and ED, email Julie Dodge, jdodge@ymcacolumbus.org, First Report of Injury Form (top section only).

AQUATIC EVENTS and RESCUES: Please notify Carrie Anders at 614-427-3554

If the media arrives on site or enters the building, welcome them but please mmediately contact your Marketing and Communications team.
Level 2 Incidents

TheftHead Injury / Potential ConcussionAltercation / FightInjured party indicates they plan to purse a claim for damages, medical bills, lost wages, or injury compensationAccident or injury that might result in an insurance or BWC claim but is not listed aboveBehavioral incident
This is a LEVEL 2 incident

What to do ALL INCIDENTS:

This form will be automatically sent to Elissa James and your location's Executive Director.

STAFF INJURIES: In addition to Elissa and ED, email Julie Dodge, jdodge@ymcacolumbus.org, First Report of Injury Form (top section only).

If it involves calling 911, or when EMS, police or fire are dispatched, please call Elissa James at 513-580-THEY (8439).
Level 3 Incidents

Minor InjurySmall Property damage that does not interrupt business operationsInsect or bug bitesPool contamination resulting in no injuriesDisciplining situationsMember disagreement
This is a Level 3 Incident.

This form will automatically be sent to the appropriate directors.

STAFF INJURIES: In addition to above, email Julie Dodge at jdodge@ymcacolumbus.org. The emergency response team will be alerted by Elissa or Julie.
Housing/Shelter Level 1 Incidents

Staff call to 911 or EMS during a major event or life threatening emergency/injury (If resident or guests call, see level 3)Cardiac Arrest (Heart attack) or deathSexually-related incidents and/or allegationsAny event requiring rescue breathing, CPR, or AED useSerious physical abuse or violenceProperty damage that interrupts business operationsPolice actions that result in an arrest
This is a Level 1 Incident.

What to do ALL INCIDENTS: Call Executive Director and notify them - They will notify Elissa James, if necessary.

STAFF INJURIES: In addition to completing this report and notifying your Executive Director, email Julie Dodge, jdodge@ymcacolumbus.org, First Report of Injury Form (top section only).

If the media arrives on site or enters the building, welcome them but follow these protocols:
Housing/Shelter Level 2 Incidents

TheftAuto accident with minor injuriesConcussion injuryStaff injury requiring medical treatmentVerbal aggression or a threat of violence by a tenant or visitorFalse fire alarmAny threat made towards a YMCA staff personIf a person indicates they plan to pursue a claim for damages, medical bills, lost wages or injury compensation
This is a Housing/Shelter Level 2 Incident.

This form will automatically be sent to the appropriate directors.

STAFF INJURIES: In addition to above, email Julie Dodge at jdodge@ymcacolumbus.org. The emergency response team will be alerted by Elissa or Julie.
Housing/Shelter Level 3 Incidents

Minor incident where ice or first aid givenGuest or resident self-reporting EMS or call to the non-emergency lineGuest/tenant disagreementPhysical/abuse without serious injuryRoutine violations of leaseTenants or guests who are uncooperative or who appear to be under the influence
This is a Housing/Shelter Level 3 Incident.

This form will automatically be sent to the appropriate directors.

STAFF INJURIES: In addition to above, email Julie Dodge at jdodge@ymcacolumbus.org. The emergency response team will be alerted by Elissa or Julie.
Is this incident a critical incident in Housing and Shelter?

NoYes
Type of Critical Incident

Medication ErrorUse of SeclusionUse of RestraintIncidents Involving InjuryCommunicable DiseaseInfection ControlAggression or ViolenceUse and unauthorized possession of weaponsWanderingElopementVehicular AccidentsBiohazard AccidentsUnauthorized Use and Possession of Legal or Illegal SubstancesAbuseNeglectSuicide and Attempted SuicideOverdoseDeathIncident Not De-escalatedCPR/AED UseEMS Called for Physical Symptom Not Related to Drugs or AlcoholCIT Officer Called for Mental Health Related Concern with No Violence
Check all that apply. Leave blank if incident does not meet any of these conditions

Call to 911Police/EMS RespondSevere injury or deathHeart attackSexually related incident or allegationAquatics rescuePhysical AbuseProperty Damage that interrupts operationsTheftHead Injury / Potential ConcussionAltercation / FightInjured party indicates they plan to purse a claim for damages, medical bills, lost wages, or injury compensationAccident or injury that might result in an insurance or BWC claim but is not listed aboveEvents requiring rescue-breathing, O2 (oxygen), CPR, or AED useBehavioral incidentMinor InjurySmall Property damage that does not interrupt business operations
Date of Incident*

MonthDayYear
Time of Incident*

:HourMinutesAM/PM Option
Location Name*
Shelter Program
Single Adult Locations

LobbyEntranceDormStaff officesServices HallwayCafeteriaRestroomLaundry RoomKitchenSmoking AreaOther
Family Side - Location

LobbyEntranceDormStaff officesServices HallwayCafeteriaRestroomLaundry RoomKitchenIndoor Play AreaOutdoor Play AreaChild WatchFamily Gathering AreaOtherOther
Specific Location*

Child Watch RoomConcession StandEntranceFitness Center - CardioFitness Center - StrengthGroup Exercise StudioGymnasiumHallwayKid's Time RoomLaundry RoomLobbyMaintenance RoomMen's BathroomMen's Locker roomMultipurpose RoomOutside (other)Parking LotPlaygroundPool / SpaResident RoomResource RoomSauna / Steam RoomSports FieldStaff OfficeWomen's BathroomWomen's Locker roomVehicleOther
Activity / Program*

DanceDay CampClimbing WallGeneral exerciseGroup ExerciseGymnasticsMartial ArtsOpen GymParent/Child ClassPersonal TrainingPreschoolResident CampSchool Age Child CareSpecial EventSwim LessonsSwim TeamWater FitnessWalking - incidentalYouth SportsYMCA Earth Service CorpsTeen ProgramOther
Vehicles Involved*
Report Submitted by*

First NameLast Name
Involved Person (Person injured or primarily involved in incident)
Status*
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Gender Identity*

MaleFemaleOther or decline to state
Date of Birth*

MonthDayYear
Age
Since this is a staff person, please make sure to complete the top section of the BWC First Report of Injury and submit to Julie Dodge.
Need to Add Additional Involved Person (separate from witnesses)

YesNo
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Gender Identity

MaleFemaleOther or decline to state
Date of Birth

MonthDayYear
Status
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General Information
Describe exactly what happened:*
Did the incident involve an injury?*

YesNo
Did Emergency Medical Services Respond?

YesNo
Did Law Enforcement Respond?

YesNo
Fully describe the injured party's condition and any First Aid given*
Time of Police / EMS arrived on scene*

:HourMinutesAM/PM Option
First Aid Administered*
First Aid Administered by*
Further Medical Attention?*
Who provided further medical attention*
With whom did the injured party leave the site?*
Was emergency contact notified?*

YesNo
Who was notified?*

First NameLast Name
Type a question
Witness Statement Uploads - Can use camera on phone to take photo
Witness Statement Uploads - Can use camera on phone to take photo

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Additional Photos
Additional Photos

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Additional Photos
Additional Photos

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Additional Photos
Additional Photos

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Max file size: 20 MB Cancelof
Additional Photos
Additional Photos

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Signature of Person Submitting Form*

Clear
If you have already completed the follow-up, click the button for "Follow-Up for Branch/Center Director" now - rather than the Submit button.

If you are not responsible for the follow-up, click the Submit button now.

Level of Incident
Incident Type
Sent to Insurer
Date Sent

MonthDayYear
Claim #
Assigned to:
Name, Phone, Email
Attorney Assigned

YesNo
Attorney Contact Info
More Info Needed

YesNo
Who was asked, when, what was asked, deadline
Status
Notes
Should be Empty:

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