Playworks Incident Report
Your information
Region
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Arizona
Colorado
Illinois
Indiana
Michigan
Minnesota
National
New England
New York and New Jersey
Northern California
Pacific Northwest
Pennsylvania
Southeast
Southern California
Utah
Wisconsin
Your
Playworks
email address
School name
Incident information
Type of incident
Please select...
Injury to student or non-Playworker
Student or adult behaviors
External incident
Level of severity
Please select...
Minor injury (scrapes/bruises/bloody nose)
Serious injury (required first aid and/or doctor visit)
Emergency (CPR/broken bone/head injury; ambulance)
Choose the option that most closely matches the incident that occurred. If unsure, contact your supervisor.
Level of severity
Please select...
Incident of violence/defiance/bullying/fighting
Multiple incidents of violence/group intimidation/angry or aggressive adults
Verbal or physical assault/non-reactive school staff to patterns of violence
Choose the option that most closely matches the incident that occurred. If unsure, contact your supervisor.
Level of severity
Please select...
Facility issues
Suspicious activities/behaviors/animals on or near play space
Lockdown/weapons/police involvement/mandated reporting/social media/news
Choose the option that most closely matches the incident that occurred. If unsure, contact your supervisor.
Date of incident
Time of incident
Exact location of incident
Where on campus did the incident occur?
Detailed description of incident
Please be thorough with your description. Include as much detail as possible to explain what happened, in what order, who was involved and action that was taken.
Were you (Playworks staff/member) a witness to or directly involved in the incident?
Please select...
Yes, I was directly involved in the incident and/or addressing it
Yes, but I was only an observer
No, I was informed about the incident after the fact
Name and grade level of all students directly involved in the incident
Please provide as much detail as possible, including first & last name and grade level for all students involved.
Name and role of all adults involved in or witness to the incident
Please provide as much detail as possible, including first & last name, role/title at school and how each adult was involved in the incident or follow-up.
Did the incident happen during Playworks programming?
Please select...
Yes
No
e.g. during Classroom Game Time, Junior Coach training, leagues or Playworks activities at recess.
Have you reported this incident to your school and/or another agency?
Please select...
Yes
No
Was the injured person(s) brought to an emergency facility?
Please select...
Yes
No
N/A
Did the involved person(s) return to Playworks activities?
Please select...
Yes
No
N/A
If students were involved, were the parent/guardian(s) contacted?
Please select...
Yes, a school staff member contacted the parent/guardian(s)
Yes, I contacted the parent/guardian(s)
No, I am not aware of the parent/guardian(s) being contacted
N/A
Submission details
Your direct supervisor's Playworks email address
Please enter only one email address
Your supervisor will be notified that this case has been submitted, but only director level staff and national support staff will be able to view case details.
If available, please attach any related documentation (copy of school incident report, CPS report, etc.)
This documentation can also be submitted later, if necessary.
By checking this box, I confirm that all information submitted in this report is truthful to the best of my knowledge
I agree
Contact Information