ASES Serious Incident/Injury Report

Your Name (Name of Person Completing this Report)* This field is required.

First Name

Last Name

Your Position* This field is required.

Site Lead

Site Lead Assistant

Youth Leader

Substitute

Area Supervisor

Other

What are you reporting?* This field is required.

Serious Incident only

Serious Injury only

Both a serious injury and a serious incident

Site Lead's Name* This field is required.

First Name

Last Name

Site Lead Email: [site lead's first initial and last name]@ymcaeastvalley.org* This field is required.This is your Site Leader's First Initial Last Name then @ymcaeastvalley.org. For example: John Doe is jdoe@ymcaeastvalley.org

School Site* This field is required.

Name of individual in charge of the student(s) at the time of the incident or injury.* This field is required.

First Name

Last Name

What is their Position* This field is required.

Site Lead

Site Lead Assistant

Youth Leader

Substitute

Area Supervisor

Other

Was the student in the "line of sight" of the staff in charge?* This field is required.

Yes

Other

If you answered "no," explain. As a reminder, Line Of Sight means you can see the students' hands and faces, and Active Supervision means you are scanning the area visually, moving through the area physically, and engaging the students proactively.

Give your statement of what you understand to have happened.

Do not state feelings or make assumptions, please.

Who? Please list each of the persons (students, staff, or others) involved that are Respondent(s), Complainant(s)/Injured, or indicate if they are Both. Do not add witnesses in this section; they are included below.* This field is required.

Was student violating program rules at the time of the incident or injury?* This field is required.

Yes

Names of Witnesses, indicate if each is a student, staff or other adult.* This field is required.

What happened? What was observed or reported? EXPLAIN what was happening when the incident occurred. (Do not include what you did afterwards. That information is included below in What action you took.) Please refer to our Incident Report Checklist to guide your response.Do not attempt to explain why the incident occurred. Just list the facts.

Do not include opinions, assumptions, or feelings.

Date and time of incident or injury* This field is required.

Date

Hour

Minutes

Where? Location where incident or injury took place (room name/# or area outdoors)* This field is required.

What action YOU took to manage the incident?

Include de-escalation steps, notifications, and follow-up.

File Upload: Upload any written statements here.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

Type of Incident (If this is an Injury Only, skip to next question.)

Bullying (includes racial/ethnic slurs)

Disruption of program time

Fighting

Inappropriate Language

Leaving campus without permission

Lying

Non-Compliance with directions or instructions

Physical Contact

Property misuse

Technology violation (phone, iPad, Chromebooks)

Unexcused Tardy

Other

Was there any property damage as a result of this incident?

Yes

Explain the property damage that occurred, including where it is/was located, what was damaged, and how it was damaged.

You can upload photos of the damage here.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

Name of Person Administering First Aid

First Name

Last Name

Were Emergency Services Contacted? (911, Ambulance)

Yes

If yes, name of person who called:

Student Receiving First Aid

First Name

Last Name

Nature of injury. Check all that apply. (If this is an Incident Only, skip to next question.)

Abrasion

Fracture

Insect bite

Chipped tooth

Contusion

Cut

Sprain

Human bite

Bruise

Concussion

Dislocation

Internal (describe area in other)

Other

Parts of body injured (check all that apply.) If this is an Incident Only, skip to next question.

Head

Finger

Arm

Abdomen

Neck

Eye

Leg

Hand

Back

Chest

Face

Foot

Other

First Aid Applied

Ice Pack

Bandage

Rest Period

Sting Relief Wipe

Other

Was an injured student released to the parent/guardian (or other authorized adult)?

Yes, complete the next section.

No, skip the next section.

If injured student was released to a parent/guardian or authorized adult, please complete this section.

Do you have another student injury to record?

Yes, the following sections will need to be completed

No, the following sections will be skipped

If an injured student left program, to whom was he/she released:

First Name

Last Name

Name of Person Administering First Aid

First Name

Last Name

Student Receiving First Aid

First Name

Last Name

Nature of injury. Check all that apply. (If this is an Incident Only, skip to next question.)

Abrasion/Scrape

Fracture

Insect bite

Chipped tooth

Contusion

Cut

Sprain

Human bite

Bruise

Concussion

Dislocation

Internal (describe area in other)

Other

Parts of body injured (check all that apply.) If this is an Incident Only, skip to next question.

Head

Finger

Arm

Abdomen

Neck

Eye

Leg

Hand

Back

Chest

Face

Foot

Other

First Aid Applied

Ice Pack

Bandage

Rest Period

Sting Relief Wipe

Other

Was an injured student released to the parent/guardian (or other authorized adult)?

Yes, complete the next section.

No, skip the next section.

If injured student was released to a parent/guardian or authorized adult, please complete this section.

Names of Witnesses and position or status (students, staff)

Parent's Name

First Name

Last Name

List the Contact Made of Parents/Guardians of Accused/Complainant/Injured* This field is required.

If a parent/guardian of a student directly involved was not contacted, please explain here.

Were parents notified?

Yes, spoke in person or over the phone.

Yes, left voicemail.

No, parents were not contacted.

Other

Parent's email (available in Jumbula)

example@example.com

Was a CANRA Reporting Form filed?* This field is required.

Yes

If a CANRA REPORT was filed, complete the following section. All fields are required.

Was a Police Report filed?* This field is required.

Yes

If a POLICE REPORT was filed, complete the following section. All fields are required.

Was a Title IX Report filed?

Yes

Was the incident submitted to the Compliance Airtable (through the links on the Redlands USD Compliance website.)* This field is required.

Yes

Was an email sent to the School Administrator (Principal or AP)?* This field is required.

Yes

Additional remarks. Please only include info relevant if follow-up is needed.If a program break or Student Success Plan is needed, please note that here.