Sample Report Form
| SAMPLE MISSISSAUGA BLUES CHILD PROTECTION POLICY INCIDENT REPORT FORM | ||
| Your Name: | Position with the Blues Club:
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| Contact Details:
Telephone No: |
Position in Club:
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| Name and Contact Details of Person Making Allegation:
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| Date & Time of Incident:
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Where incident took place: | |
| Type of Incident:
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| Child/Young Person’s Name
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Age (if known):
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| Parent/Carer’s address:
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Telephone No:
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| Name of adult against whom allegation is made:
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Position in Club:
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| Contact Details:
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| Relationship between adult (against whom the allegation has been made) and child/young person,
if any:
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| Details of Incident:
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| Were there any witnesses? If so, please state name and contact details:
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| If Child/Young Person spoke to you directly, please record actual details and words used by the child. (Remember do not lead or question the child or young person.
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| Action taken so far by you:
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| Referred to Child Protection Officer:
Yes/No and when?
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| Any other information:
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