Report abuse or safeguarding concerns

Safeguarding or abuse reporting form

Dear member,

Please use this form to report safeguarding incidents. Be as factual as possible. Remember that this must remain confidential except to those who are allowed to see it and must be kept in a locked place at all times. Ensure that the information is correct and accurate. Your form will be sent to our Club Welfare Officer (CWO), who will act on the situation as per the regulations.

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Your Full Name

Your Phone

Your Email

Your address

Child’s Full Name

Child’s Gender(required)

Male

Female

Child’s Date of Birth

Child’s Ethnic Origin

Parent/Carer’s Name

Parent/Carer’s Phone

Parent/Carer’s Email

Parent/Carer’s Address

Parent/Carer has been notified of this incident

Details of what was said to Parent/Carer

Are you reporting your own concerns or concerns raised by someone else?(required)

Own concerns

Concerns raised by someone else

If responding to concerns raised by someone else, please provide further
information (Name, Position within club/event, Telephone numbers, Email address)

Date and time of incident (YYYY-MM-DD)

Details of incident or concern: Include all relevant information, such as
description on any injuries and whether you are recording this incident as fact,
opinion or hearsay

Child’s account of the incident

Details of any witnesses to the incident (Name, Position within club/event, Telephone numbers, Email address)

Details of any person involved in this incident or alleged to have caused the incident/injury (Name, Person within the club or relationship to the child, Telephone numbers, Email address)

Please provide details of action taken to date

The incident has been reported to external agencies?

If yes, name of organisation/agency, Contact person, Telephone numbers, Email address, Agreed action or advice given

Signature

Full Name

Date (YYYY-MM-DD)

Monmouth And District Angling Society

Safeguarding or abuse reporting form

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