�

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.

�

Social Services yes/no

Social Services
yes/no