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Home Page >> What we do >> Community >> Child Protection Good Practice >> Recording your Concerns

 

How to Record Your Concerns

                     (Club or organisation)

     CHILD PROTECTION

SAMPLE INCIDENT RECORD FORM

 

Club or Agency:

Your name:

 

Your position:

 

Child’s name:

 

Child’s address:

 

 

Parents/carers names and address:

 

 

Child’s date of birth:

 

Date and time of any incident:

 

 

Your observations:

 

 

 

 

Exactly what the child said and what you said:

(Remember, do not lead the child – record actual 
details. Continue on separate sheet if necessary)

 

 

 

 

 

Action taken so far:

 

 

 

 

 

External agencies contacted (date & time)

 

Police              yes/no

 

If yes – which:

Name and contact number:

Details of advice received:

 

 

 

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 Council or Education Department

yes/no 
(If appropriate)

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 Governing Body Child Protection Officer for monitoring purposes.

 
 
 

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Last modified: Thursday October 21, 2020.