Report form

BAACS Incident Report Form (please print or contact seccy)

 Use for reporting of concerns relating to poor practice, bullying, cases of emotional or physical neglect or abuse, or sexual abuse

Please print and complete email or contact trousec@gmail for further advice

 

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:

Contact BAACS Welfare Officer in line with reporting procedures.

 troutsec@gmail.com