Reporting a Safeguarding Concern

Section 1: General Incident Information
Date Incident Occurred*
Please indicate the date the incident occurred
Date Format: DD slash MM slash YYYY
Time Incident Occurred*
Please indicate the time the incident occurred

: HH

MM
Date Reported*
When was this reported?
Date Format: DD slash MM slash YYYY
Source of Referral*
Please select the source of the referral
Source of Original Disclosure*
Please select the source of the original disclosure
Context of Concern*
Please select the context of concern for this incident(s)
Online/Offline*
Please select whether the incidents occurred online or offline
Region*
Please select the region of the country where the incident(s) occurred
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?*
Category of Concern (If Child)
Category of Concern (If Adult)

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*
Ethnicity*
Disability*
Age at Time Incident*
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)
Date Format: DD slash MM slash YYYY
Age at Time Incident*
Gender*
Principal Victim?*
- Yes
- No
Primary Role*
Secondary Role (If applicable)
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*

Section 1: General Incident Information