Safeguarding Incident Referral Form

This form should be used to record any safeguarding or welfare incident or concern that is brought to your attention. Details should be recorded as soon and as accurately as possible.

Remember to maintain confidentiality on a need to know basis. Only disclose information if it will protect the child.

All fields are required unless otherwise stated.

Your details

Please complete your details as best you can

Club Name

Optional.

Position in the club (if applicable)

Optional.

Your name

Address

Optional.

Email Address

Contact e-mail

Optional.

BWSW Membership No.

Optional. If you don't know then leave blank

Are you reporting your own concerns or responding to concerns raised by someone else?

Concerns raised by someone else

Optional. My own concerns

If responding to concerns raised by someone else, please provide details of the person who raised the concerns;

Optional. Name, email, position in club and contact number if possible

Details of the person the concern is attributed to

Please provide details below

Name

Optional.

Position in the club (if applicable)

Optional.

Relationship to complainant i.e coach, volunteer

Optional.

Have they been notified of the allegation against them? NB. This should only happen in a case of poor practice, not in a case of suspected child abuse

Optional.

Details of complainant

Please provide details below

Name

Optional.

Date of birth

Optional.

Sex

Optional.

Age

Optional.

Ethnicity

Optional.

Disability/Impairment

Optional.

Parent/carer's address

Optional.

Parent/carer's contact details

Optional.

Have the parents/carers been notified of the incident? (if applicable)

Optional.

If yes, please provide details of what has been said

Optional.

Details of the incident

Please provide as much information as possible

Date/period

Optional.

Time

Optional.

Please give a brief description of the incident or what has prompted your concerns;

Optional.

If you have spoken to the complainant, please give details of what was said and when;

Optional.

Please outline what action has been taken so far;

Optional.

Please indicate if you have been in contact with any other organisations concerning this incident i.e BWSW, Police, Social Services, Local Safeguarding Authority

Optional. Name, number, date, details of advice

Verification

Click the box

Please click the box to indicate you are a human rather than an automated system completing this form.

Last step

Please ensure all fields are completed as accurately as possible before submitted.

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Safeguarding Incident Referral Form