YMCA of Metro Denver Incident Report

Nationwide Incident Report: Part 1
Please contact Sandy at smcclain@denverymca.org for additional comments or questions.
Association*
Branch*
Hidden
Branch
Off-site Facility
Injured Person*
First Last
Phone - Daytime*
Phone - Evening*
Address*
Street Address Address Line 2 City State ZIP Code
Check here if the injured person is under the age of 18.
- Injured Person is under the age of 18
Parent / Guardian
If under the age of 18.
First Last
Address*
Street Address Address Line 2 City State ZIP Code

Witnesses
(Check box to indicate staff [s], participant [p], or volunteer [v]; indicate age for youthful witnesses)
Witness - 1
- Staff
- Participant
- Volunteer
Witness Name - 1*
First Last
Witness Phone - 1*
Witness Address - 1*
Street Address Address Line 2 City State ZIP Code
Witness - 2
- Staff
- Participant
- Volunteer
Witness Name - 2*
First Last
Witness Phone - 2*
Witness Address - 2*
Street Address Address Line 2 City State ZIP Code
Witness - 3
- Staff
- Participant
- Volunteer
Witness Name - 3*
First Last
Witness Phone - 3*
Witness Address - 3*
Street Address Address Line 2 City State ZIP Code

Incident Details
Please select one of each of the following sections.
Specific Location of Incident*
Other*
Program: (Indicate Name)*
Program:*
Other*
General Activity*
Other*
Specific Action*
Other*
Source of Injury*
Other*
Apparent Injury*
Other*
Body Part: Please check all that apply.
Hold down CTRL to select multiple fields.
Body Part*
Other*
Comments:
Administrative Use Only:
1: Potential Claim Incidents should be faxed immediately to: 720-524-2701
2: All incident reports should be batched at least weekly and emailed to: smcclain@denverymca.org

3: claim number
4: adjuster name and contact

Nationwide Incident Report: Part 1