Incident Report Incident Report Incidents and accidents may involve minor to major physical injuries of participants and/or program staff, behavioral issues, hospital/doctor visits, or over-the-counter medication disbursement. A person having cause to believe that a minor’s physical or mental health or welfare has been adversely affected by abuse, neglect, or other maltreatment by any person shall immediately make a report to local law enforcement. Please submit the following information within 24 hours of any incident involving injury to or affecting the health or safety of a participant. Program/Event Name: * Session Name (if applicable): Host Organization/Department: * Report Date/Time: * Date/Time of Incident: * Remember: Incident Reports must be submitted to University Youth Programs within 24 hours of the incident's occurrence. Location of Incident: * Detailed Description of Incident: * Root Cause of Incident: Corrective Action(s) Suggested: Did University Police respond? * Yes No Officer Responding: Please indicate N/A if the incident did not involve law enforcement. Incident Report Number: Did anyone receive treatment at a medical facility? * Yes No Where? Please indicate N/A if the incident did not involve treatment at a medical facility. Transport Provided By: Was an insurance claim report filed? * Yes No Reporting Party Name: The reporting party is the individual filing the incident report. Reporting Party Phone Number: Reporting Party Email: Party 1 Name: * Please provide the information for the involved parties of the incident. Party 1 Address: * Party 1 Phone Number: * Party 1 Parent/Legal Guardian: * Party 2 Name: Party 2 Address: Party 2 Phone Number: Party 2 Parent/Legal Guardian: Witness 1 Name: Please provide the information for any witnesses to the incident, if different from the reporting party. Witness 1 Phone Number: Witness 1 Address: Witness 2 Name: Witness 2 Phone Number: Witness 2 Address: Submit If you are human, leave this field blank.