Sullivan Group/Hanover Incident Reporting Form for YMCAs

All fields marked with * are required

Injured Person
Gender *
Age *
Status *
Parent / Guardian
Incident Information

Use format HH:MM; Please indicate AM or PM.

Describe exactly what happened.

Fully describe the injured party's condition and any first aid given.

Blood-borne exposures *
Specific Location of Incident *
General Activity *
First aid administered?
Further medical attention required? *
Was parent/guardian/emergency contact notified? *
Witness

Select radio button to indicate staff [S], participant [P], or volunteer [V]; Indicate age for youthful witness

Witness 1
Witness 2
Witness 3
Incident Management
Waiver Format *
Waiver Wording *
Staff Member Filing Report
Exec. Dir. Reviewing Report
Filed with: *
Method of filing: *
Follow-Up
Was there a follow-up contact? *