Greater Philadelphia YMCA Child Protection Reporting Form
The purpose of this form is to report suspected abuse of a child or vulnerable adult. The information you provide will be kept confidential and will be reviewed by the risk management team.
Individual Filing Complaint
(Optional)
Role
(i.e. Consumer or Parent/Guardian
Date of Occurrence
Time of Occurrence
Other Individuals Involved?Witnesses to Complaint
Type of Complaint
Inappropriate Behavior by Employees/Volunteers
Inappropriate Behavior by Consumers
Retaliation
Whistleblower Complaint
(Select all that apply)
Describe the situation:
What happened, where did the incident occur, when did it happen, who was involved, who was present, who was notified? If abuse is suspected was it reported to the State?
Describe the remedy you seek.
Please list all remedies sought as a result of bringing this grievance. What would you like to see happen to solve the issue?
Submitted By
(Optional)
Email
Optional
Phone Number
Optional
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