Instructors - Child Protection Sample Incident Form

Child Protection Sample Incident Record Form

Club or Agency:
Your name:

Your position:

Contact number:
Child’s name:

Child’s address:

 

Parents/carers names and address:

 

Contact number:
Child’s date of birth:
Date and time of any incident:

Your observations or details as reported to you:

 

 

Exactly what the child said and what you said:
(Remember, do not lead the child – record actual details. Continue on separate sheet if necessary)

 

 

 

If you are passing on someone else's concerns, record their name, address, position and contact number

 

 

 

Action taken so far:

 

 

 

External agencies contacted (date & time)

Police
Yes/No

 

If yes – which:

Name and contact number:

Social Services
Yes/No

 

If yes – which:

Name and contact number:

Details of advice received:

 

 

Sport Governing Body
Yes/No

Name and contact number:

Details of advice received:

 

 

Local authority
Yes/No

If yes – which:

Name and contact number:

Details of advice received:

 

 

Other (e.g. NSPCC)

Which:

Name and contact number:

Details of advice received:

 

 

Signature:
Print name:

Date:

Remember to maintain confidentiality on a need to know basis – only if it will protect the child. Do not discuss this incident with anyone other than those who need to know.
NB: A copy of this form should be sent to social services after the telephone report and to the (Sport) Child Protection Officer.

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