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.

Suggestion or Complaint?

For suggestions, complaints and report house rules or code of conduct violations, use our Suggestions and Complaints Form.

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

MM

DD

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