Match-Aid Incident Reporting Form




Incident reporting form


Your name:                

Name of organisation:

Your role::   

Contact information (you):   

Address:   

Postcode:

Telephone numbers:                                           Email address:

Child’s name:                                                       Child’s date of birth:
   
Child’s ethnic origin:                                           Does child have a disability:

       
       
Child’s gender:   
□    Male   
□    Female   

Parent’s / carer’s name(s):   


Contact information (parents/carers):   

Address:                                                                  Postcode:

Telephone numbers:                                              Email address:

Have parent’s / carer’s been notify of this incident?
□    Yes   
□    No   
If YES please provide details of what was said/action agreed:

Are you reporting your own concerns or responding to concerns raised by someone else:
□    Responding  to my own concerns   
□  Responding to concerns raised by someone else

If responding to concerns raised by someone else:    Please provide further information below

Name:   

Position within the sport or relationship to the child:   

Telephone numbers:                                                   Email address:

Date and times of incident:

Details of the incident or concerns:

Include other relevant information, such as description of any injuries and whether you are recording this incident as fact, opinion or hearsay.






Child’s account of the incident:





Please provide any witness accounts of the incident:






Please provide details of any witnesses to the incident:



Name:

Position within the club or relationship to the child:

Date of birth (if child):

Address:    Postcode:

Telephone number:    Email address:

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



Name:

Position within the club or relationship to the child:   

Date of birth (if child):   

Address:                                                              Postcode:

Telephone number:                                            Email address:

Please provide details of action taken to date:   




Has the incident been reported to any external agencies?
0Yes
0No

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 Match-Aid’s Designated Safeguarding Officer in line with Match-Aid’s reporting procedures.
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