Report form

1.      Name of organisation:

2.      Your name:

3.      Your position:

4.      Your contact information:

Address: 

Telephone number: 

Email address: 

5.      Name of Person of concern:

6.      Is the person under 18?  (If no, go to question 12)

c    Yes

c    No

7.      Child’s date of birth:

8.      Parent/Carer’s name(s):

9.      Person or Parent/Carer’s contact information:

Address:  

Telephone number:  

Email address:  

10.  Have parents/carer been notified of this incident:

c    Yes

c    No

11.  If YES, please provide details of what was said:

12. Person’s gender:

13. Person’s ethnic origin:

14.  Are you reporting your own concerns or responding to concerns raised by someone else:

c    Own concerns

c    Concerns raised by someone else

15.  If responding to concerns raised by someone else, please provide further information:

Name:  

Position within club/event:  

Telephone numbers:  

Email address:  

16.  Date and time of incident:

17. Details of incident or concern: Include all relevant information, such as description on any injuries and whether you are recording this incident as fact, opinion or here say.

18.  Child’s account of the incident: Complete if this report relates to a child

19.  Please provide any witnesses accounts of the incident:

20.  Please provide details of any witnesses to the incident:

Name:  

Position within club/event:  

Telephone number:  

Email address:  

21.  Please provide any details of any person involved in this incident or alleged to have caused the incident/injury:

Name:  

Person within the club or relationship to the child:  

Date of birth:  

Address:  

22.  Please provide details of action taken to date:

23.  Has the incident been reported to any external agencies?

c    Yes

c    No

24.  If YES, please provide further details:

Name of organisation/agency:  

Contact person:  

Telephone numbers:  

Email address:  

Agreed action or advice given:  

Your signature:

Print name:

Date: