CONFIDENTIAL

Report No:
__________

POINTE-CLAIRE SWIM CLUB INCIDENT REPORT FORM

Name of Club
Name(s), Group(s) of
Swimmer(s) Involved

__________________________________________________
__________________________________________________
__________________________________________________

Location of Incident
(please specify)

At a location in the pool or on pool property

__________________________________________________

At a swimming competition __________________________

At a PCSC related activity ___________________________
On a bus ________________________________________
Other ___________________________________________
Time of Incident

Date: ___________________________ Time: ____________

Type of Incident
(check all that apply)

Activities for which suspension must be considered

Possessing or being under the influence of alcohol,
cigarettes or illegal drugs
Sexual harassment or sexual fraternization

Bullying
Physical Aggression: _________________________
Social Aggression
Verbal Aggression
Intimidation
Harassment
Other: _____________________________________
Uttering a threat to inflict bodily harm on another person
Disrespect towards teammates, competitors, coaches,
officials, administrators, parents or another person in position of
authority
Committing an act of vandalism that causes extensive
damage to pool property at the swimmers pool or to property
located on the premises of the swimmers pool
Any other activity for which a swimmer may be suspended
under club policy: ____________________________________
Activities for which expulsion must be considered
Giving alcohol to a minor

Trafficking in weapons or illegal drugs

Committing sexual assault

 Committing robbery
Any discriminatory behavior that is motivated by bias,
prejudice, or hate
Bullying (if the swimmer has been previously suspended for
engaging in bullying and the swimmers continuing presence in
the club creates an unacceptable risk to the safety of another
person)
Committing physical assault on another person that causes
bodily harm requiring treatment by a medical practitioner
Possessing a weapon, including possessing a firearm

Using a weapon to cause or to threaten bodily harm to

another person
Any other activity for which a swimmer may be expelled:
__________________________________________________
Description of Incident: __________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Witnesses:
(1) Name: ______________________________________________________________
Role in PCSC Community: ________________________________________________
(2) Name: ______________________________________________________________
Role in PCSC Community: ________________________________________________
Report Submitted By:
Name: ________________________________________________________________
Role in PCSC Community: ________________________________________________
Signature:________________________________________

Date: _______________

Contact Information: Phone: _______________ E-mail: __________________________

Communication with Club:___________________________

Date: _______________

FOR HEAD COACHS USE ONLY:

Investigation in progress
Meeting date with swimmer(s) and parent(s) involved: ____________________
Investigation completed
Head Coach to communicate results to coaches at a mutually convenient time
Name of Head Coach: ____________________________________________________
Signature:________________________________________

Date: _______________