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You are here:
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The British Judo Association (BJA)
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Safeguarding
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Reporting a Safeguarding Concern
Step
1
of
4
25%
Section 1: General Incident Information
Date Incident Occurred
*
Please indicate the date the incident occurred
DD slash MM slash YYYY
Time Incident Occurred
*
Please indicate the time the incident occurred
:
Hours
Minutes
Date Reported
*
When was this reported?
DD slash MM slash YYYY
Source of Referral
*
Please select the source of the referral
Please select the source of the referral
Anonymous
Another Sports Organisation
Club member
Club Welfare Officer
Coach
County/Regional Welfare Officer
Other
Other Club Officer
Parent
Peer
Statutory Agency
Unknown
Victim
Source of Original Disclosure
*
Please select the source of the original disclosure
Please select the source of the original disclosure
Anonymous
Another Sports Organisation
Club member
Club Welfare Officer
Coach
County/Regional Welfare Officer
Other
Other Club Officer
Parent
Peer
Statutory Agency
Unknown
Victim
Context of Concern
*
Please select the context of concern for this incident(s)
Please select the context of concern for this incident(s)
Occurred in sport
Occurred out of sport
Both
Not Known
Online/Offline
*
Please select whether the incidents occurred online or offline
Please select whether the incidents occurred online or offline
Online
Offline
Both
Not known
Region
*
Please select the region of the country where the incident(s) occurred
Please select the region of the country where the incident(s) occurred
East Midlands
East of England
Greater London
North East
North West
Northern Ireland
Scotland
South East
South West
Wales
West Midlands
Yorkshire and Humberside
County
*
Please indicate the county where the incident(s) occurred.
Club
*
Please enter the name of the club where the incident(s) occurred
Is Victim an Adult or Child?
*
Please select an option
Adult
Child
Category of Concern (If Child)
Please select an option
General Welfare Concern
Sexual abuse: contact
Sexual abuse: non-contact
Physical abuse
Emotional abuse
Bullying by peers
Neglect
Poor Practice
Other (please provide further information in the details box on the next page)
Category of Concern (If Adult)
Please select an option
Cyber Bullying
Domestic Abuse
Discriminatory
Emotional or Psychological
Financial or Material
Forced Marriage
Hate Crime
Modern Slavery
Neglect and Acts of Omission
Organisational
Physical
Radicalisation
Self-neglect
Sexual
Section 2: Victim Sub-Form
(Please complete as many Victim Record forms as applicable for this case; only one of the Victims should be deemed to be the “Principal Victim”)
Name
*
First
Last
Gender
*
Please select
Male
Female
Other
Ethnicity
*
Please select
Asian or Asian British – Bangladeshi
Asian or Asian British – Indian
Asian or Asian British – Pakistani
Asian or Asian British - Any Other Asian background
Black or Black British – African
Black or Black British – Caribbean
Black or Black British - Any Other Black background
Chinese
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Mixed - Any Other Mixed Background
White – British
White – Irish
White - Any Other White Background
Any Other
Not Known / Not Provided
Disability
*
Please select
None
PMLD – Profound and multiple learning difficulties
SLD – Severe learning difficulties
MLD – Moderate learning difficulties
ASD – Autistic spectrum disorder
PD – Physical disorder
Age at Time Incident
*
Please select
0-4
5-9
10-14
15-17
18-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85 and over
Principal Victim?
*
Yes
No
Section 3: Subject of Concern Sub-Form
Please complete as many Subject of Concern forms as applicable for this case; only one of the Subjects of Concern should be deemed to be the “Principal Subject of Concern”)
Name
*
First
Last
Date of Birth (If known)
DD slash MM slash YYYY
Age at Time Incident
*
Please select
0-4
5-9
10-14
15-17
18-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85 and over
Gender
*
Please select
Male
Female
Other
Principal Victim?
*
Yes
No
Primary Role
*
Please select
Child
Parent
Coach
Referee/Umpire/Official/Other
Anonymous
No Victim
No Role
Secondary Role (If applicable)
Please select
Child
Parent
Coach
Referee/Umpire/Official/Other
Anonymous
No Victim
No Role
Registered/Licenced
*
Yes
No
Rule/Policy Breached
*
Suspension
*
Yes
No
Section 4: Details of what happened
Please provide further details of your concern:
*
Please provide an email address for us to contact you to discuss the issue further
*
Contact Phone Number
*
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