Incident Report

This form should be completed within 24 hours of when the incident occured.

An indicent is defined as any event that results in the injury of a person, facility or piece of equipment or other situation that requires the intervention of a Person of Authority to resolve. This can include, but is not limited to, a rolled ankle, a broken light fixture or net, a verbal altercation between two people taht required intervention.

In programming without a Person of Authority or other Organization Official, Team Captains are required to report incidents to the League Coordinator and Vice-President, Operations. The League Coordinator or Vice-President, Operations must then complete this Incident Report based on the information received within 24 hours.

Your Name

First Name

Last Name

Your Email

Your Phone Number

(###)

###

####

Full Names of People Involved in the Incident (if available)

Date of the Incident

YYYY

Description of the Incident

Was 9-1-1 or other emergency services contacted or involved?

What was the related program or event?

e.g. drop-in, gala, wednesday tiered league, etc.

What action was taken during the incident?

Recommended follow up action

Agreement

I certify that the information provided in this Incident Report is true, accurate and complete to the best of my knowledge and belief. I understand that providing false information could result in serious consequences including disciplinary action or legal penalties. I also understand that this Incident Report may be used for official purposees including investigations and legal proceedings, and I am prepared to cooperate fully in any such processes. I am aware that it is my responsibility to report any new information or changes related to the incident as soon as possible if I become aware. I affirm that I have read and understood the above statements.

I agree