Accident/ Incident It is recommended that you complete this form electronically. You will have an opportunity to review your submission prior to submission at which point it will be transmitted directly to Special Olympics Ontario with a copy to yourself. Step 1 of 9 11% Accident / Incident ReportThis form should be completed for all accidents, injuries and incidents in which SOO athletes, volunteers or spectators are involved. Please complete this form to the best of your ability. If completing this report by hand. Please print this form and fax it to Special Olympics Ontario at 416 447 6336. It is recommended that you complete this form electronically. You will have an opportunity to review your submission prior to submission at which point it will be forwarded directly to Special Olympics Ontario, a copy will also be sent to your e-mail.Nature of Accident / Incident Report* Behavioural Incident Suspected/ Confirmed Concussion Minor Medical Emergency Major Medical Emergency Physical Injury Property / Environmental Damage Theft Code of Conduct Violation Improper / Inappropriate Conduct Spectator Incident Assault Other Please check all labels that apply to this report / accident / incident A. REPORT INFORMATIONInformation pertaining to the individual completing this report.Report Completed by* First Last Phone*Email* Position/Title*Head CoachCoachTeam ManagerCommunity CoordinatorVolunteerOfficialFirst Aid ResponderParent/GuardianFacility/Program StaffEducatorEvent Organizer (non- SOO)SOO Staff B. ATHLETE / VOLUNTEER INFORMATIONInformation pertaining to the individual injured or the subject of this incident.Type of Participant Athlete Volunteer Student (in School Program) Educator Staff Spectator Please select the best description for the individual involved in this accident. Only select Student or Educator if the event or practice was part of a school program.Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneClub Name If applicable the name of the club to which this volunteer / athlete is affiliated.Head Coach Name First Last If this form is for a coach or athlete please provide the name of the head coach of the program in question.Community Name If known please provide the Community in which this athlete / volunteer is located. C. NATURE OF ACCIDENT / INCIDENT (INCLUDING LOCATION AND EXTENT)Location of Accident / IncidentDetails about the location of the Accident / IncidentDistrictUnknownSouth WestSouth CentralGTAEasternCentralNorth EastNorth WestIf known, the SOO Region in which this incident took place.Date of Accident / Incident MM slash DD slash YYYY Time of Accident / Incident : Hours Minutes If known the approximate time of the accident.Details of Accident/ Incident D. ACCIDENT / INCIDENT SUMMARYBriefly describe the circumstances leading to the accident / incident:Was a coach, volunteer or parent supervising? Yes No Was there supervision at the time of the accident? If yes please indicate the name of the supervisor below.If yes, name(s) of those supervising:Please include the contact information for individuals supervising (if not included in the contact information section above)Was anyone else involved? Yes No If yes, please describe who, and how:Please include relevant contact information if appropriate. Please note that a separate accident/incident report may be required if more than one party was INJURED in this incident. E. ACTIONS TAKEN OR TREATMENTPlease indicate the treatment provided with regard to this accident or where relevant follow up or corrective actions taken.Actions Taken/ TreatmentBy whom: Name of the person providing treatment / follow up (where possible please provide contact information)Was the athlete/volunteer sent home? Yes No If yes, how, and with whom?Was athlete/volunteer sent to hospital? Yes No If yes, how, and with whom? F. CONTACT NOTIFICATIONSPertaining to individuals / organizations notified as follow up to this accident / incident.Was a doctor called? Yes No Not Required Name of DoctorIf yes please indicate the name of the doctor and their contact information as well as the name of the person who contacted them.Date MM slash DD slash YYYY Date of notificationTime : Hours Minutes AM PM AM/PM If known, approximate time of notification.Was parent or guardian notified? Yes No Not required Was Special Olympics Ontario staff present or notified following the incident?Name of Parent/ GuardianPlease note the name of the parent or guardian contacted as well as the name of the person who contacted them. Date MM slash DD slash YYYY Date of notificationTime : Hours Minutes AM PM AM/PM Approximate time of notification.Was Special Olympics Ontario notified? Yes No Was Special Olympics Ontario staff present or notified following the incident?Name of StaffName of SOO Staff notified and please indicate who notified the staff member. Date MM slash DD slash YYYY Date of notificationTime : Hours Minutes AM PM AM/PM Approximate time of notification. G. OTHERList witnesses to accident / incident:If there were additional witnesses to this accident / incident please include their names and contact information here.Please add any further information which you consider important:If you have any supporting documentation, attachments or files that are relevant to this report please upload them into the spaces below.Max. file size: 512 MB.Upload File 1FileMax. file size: 512 MB.Upload File 2FileMax. file size: 512 MB.Upload File 3 H. RELEASE* I understand that the information contained in this report may be deemed confidential. As a participating Volunteer, I may be dealing with confidential information and I agree to keep such information in the strictest confidence. * I agree to abide by the Special Olympics Canada Inc. and Special Olympics Ontario Inc. rules, policies and procedures and Code of Conduct. * I affirm that I have read the above and that the information I have given is true and complete. Type your name here to verify your understanding of the above statementsType your name here to verify your understanding of the above statements*
