Karate Issues - Child Protection Incident Form

Child Protection Sample Incident Record Form. Reproduced with kind permission from the Child Protection in Sport Unit.

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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