BYC Incident Report Form
This form is to be completed by the main staff/director/member/volunteer who dealt with the situation whenever there is an incident which could include accidents with or without injury as well as facility or behaviour related incidents. When completing this form only include an actual factual description of the incident without assumptions or conclusions as to cause or responsibilities. Attach extra sheets if needed.
Forms should be completed within 24 hours and submitted to the Vice Commodore. Remember they are considered confidential and should be kept secure.

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Name of Person Involved *
Parent Name if Person is a Minor
Program
Address
Phone and Email *
Age
Full Name - Second Person Involved In Same Incident
Parent Name of Second Person if a Minor
Program
Address
Phone and Email
Age
Day and Date of Incident *
JJ
/
MM
/
YYYY
Please describe the incident. State only the facts that you are sure of at the time. Include a description of the weather, visibility, and any other external factors. Send drawings, diagrams and photographs if these will aid in the description. *
What was done to assist or respond to incident and by whom? *
If medically related, was person advised to seek medical assessment: *
If Suspected Concussion, either disclosed or through incident, did the following take place?
Was 911 called? *
Name and Badge Number for Police, Ambulance and Fire Unit
List Witnesses - Name, Phone and Email
Person Completing the Report *
Thank you for completing the report. This will be automatically sent to the Vice Commodore when you press send.
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