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

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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:

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:

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Name and contact number:

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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)

If yes � which:

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Name and contact number:

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Details of advice received:

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Other (e.g. NSPCC)

Which:

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Name and contact number:

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Details of advice received:

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Signature:

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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.

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Social Services yes/no

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Social Services
yes/no