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How to Record Your
Concerns
(Club or organisation)
CHILD PROTECTION
SAMPLE INCIDENT RECORD FORM
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Club
or Agency:
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Your
name:
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Your
position:
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Child’s
name:
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Child’s
address:
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Parents/carers
names and address:
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Child’s
date of birth:
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Date
and time of any incident:
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Your
observations:
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Exactly
what the child said and what you said:
(Remember,
do not lead the child – record actual
details. Continue on separate sheet if necessary)
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Action
taken so far:
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External
agencies contacted (date & time)
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Police
yes/no
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If
yes – which:
Name
and contact number:
Details
of advice received:
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Social
Services
yes/no
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If
yes – which:
Name
and contact number:
Details
of advice received:
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Sport
Governing Body
yes/no
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Name
and contact number:
Details of advice received:
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Local
Council or Education Department
yes/no
(If appropriate)
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If
yes – which:
Name
and contact number:
Details
of advice received:
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Other
(e.g. NSPCC)
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Which:
Name
and contact number:
Details
of advice received:
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Signature:
Print
name:
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Date:
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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. |
