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Serious Situation Response - Staff Form - Big Brothers Big Sisters of Peel York
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Serious Situation Response – Staff Form

Serious Situation Response Form – BBBSPY Local Practice

This form is to be completed by Agency Staff to record incidents, situations, disclosures, and/or discoveries that impact the well-being of members of the BBBSPY community (i.e. Mentees, Mentors, volunteers, families, staff, placement students, etc.) that may or may not be related to their involvement with BBBSPY.

This form should NOT be used in the event of an allegation of abuse related to BBBSPY participation. In those cases, BBBSC Appendix C – Confidential Reporting Form – Allegation of Abuse must be completed.

Examples of Serious Situations includes a threat to safety or disclosure of abuse unrelated to program participation, self-harming behaviour, extreme food or housing insecurity, conflict between program participants, injury or incident at BBBSPY program or event, etc.

When in doubt, please contact your Supervisor.

INSTRUCTIONS

1. Please fill out this form with the information you are able to collect;
2. If you do not know the information, please leave the section(s)/field(s) blank;
3. If the section(s)/field(s) are not applicable, please write Not Applicable or N/A;
4. Please submit the completed form within three (3) business days of becoming aware of the incident/situation.
Name of Staff Submitting this Form(Required)

REGARDING

MM slash DD slash YYYY
Select the individual(s) involved in this incident/situation(Required)
Select all that apply
Enter the name of the primary BBBSPY community member involved(Required)
I.e. Mentee, Mentor, Parent/Caregiver, Staff, Student, etc.
If applicable, enter the name of the secondary BBBSPY community member involved
I.e. Mentee, Mentor, Parent/Caregiver, Staff, Student, etc.
If there are other BBBSPY parties involved, please provide their full name in the Details box below.
Select the type of Serious Situation you are reporting(Required)
Select all that apply

INCIDENT/SITUATION DETAILS

Provide as much information as possible.
This may be the same date listed above.
MM slash DD slash YYYY
Include full names of all BBBSPY community members involved in this incident/situation.
Include how you became aware of this incident/situation.
Include all other details you are aware of.
Has Children's Aid Society been informed of this situation?(Required)

Enter the full name of the person who notified or will be notifying CAS
Has your Supervisor already been made aware?(Required)
Follow up with your Supervisor immediately after submitting this form.
Thank you for informing your Supervisor. They will also receive a copy of this submission.
Has this incident/situation already been documented in SDP?(Required)
Enter this information into SDP immediately after notifying your Supervisor.
Thank you for entering this information in SDP.
Thank you for submitting this form. If you become aware of any further pertinent information, please continue to document those details in SDP and inform your Supervisor.
This field is for validation purposes and should be left unchanged.
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Head Office
71 West Drive, Unit 23 Brampton, ON L6T 5E2
Email: info.peelyork@bigbrothersbigsisters.ca Telephone: 905.457.7288 Contact us York Office: 350 Industrial Parkway S. Aurora ON Canada L4G 3V7 Email: info.peelyork@bigbrothersbigsisters.ca Telephone: 905.457.7288
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© 2025, Big Brothers Big Sisters of Peel York

Charitable Business Number: 118809482RR0001

Start Something™ Reg. CIPO Big Brothers Big Sisters of Canada.
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We recognize the importance of language and its impact on inclusivity and representation.  We acknowledge that our organizational name reflects the gender binary and does not fully honor the experiences of trans, non-binary, and gender-diverse individuals. However, BBBSPY is deeply committed to creating an inclusive and affirming environment where all identities are reflected in the work we do. We proudly welcome 2SLGBTQIA+ Mentors, Mentees, and staff members, and we are dedicated to advancing the development of PRISM—a service created by and for the 2SLGBTQIA+ community.

 

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