Incident Report Form

South Australian Ice Hockey Association Inc
P.O. Box 20 Woodville S.A. 5011
E: secretary@icehockeysa.com.au
W: https://icehockeysa.com.au/
ABN: 24 328 733 422

This form is to be used by Members of the South Australian Ice Hockey Association Inc. (IHSA), to report any incident of unacceptable behaviour. An individual is considered to be displaying unacceptable behaviour if they violate the ‘Rules and Code of Conduct’ in any way including, but not limited to: verbally or physically harassing and / or abusing any other Member of IHSA or any Spectator or bringing the Association into disrepute.

PLEASE NOTE - If you are reporting an Injury during a game please use the In-Game Injury Report instead.

Does this report relate to a specific incident?*

This DOES relate to a specific incident (can be on more than one date)This relates to a process or policy, not a specific incident

Location of the Incident:*

Date & Time of Incident:*

Date

Hour MinutesAM/PM Option

Name of Alleged Offender(s):*

Club or Team Name:

Name(s) of Witnesses:

Description of the Incident / Unacceptable Behaviour or Policy / Process of concern:*

Do you have any relevant supporting documentation related to this incident report? Please upload here.

If this matter progresses to investigation and / or goes to Tribunal, are you available to provide additional information if required?*

YesNo

Do you request to remain anonymous from the alleged Offender(s)?*

YesNo

Do you understand that remaining anonymous alleged Offender(s) may restrict the matter from progressing to investigation?*

Yes

PLEASE NOTE - All reports are treated confidentially. If we need to disclose your details in order for the matter to progress, you will be advised prior to this occuring.

If you are concerned about your or another persons safety by making this report, please contact the IHSA Member Protection Officer directly.

membersprotection@icehockeysa.com.au

Your Name*

Mob Phone

E-mail*

example@example.com

Signature*

Submission Date*

Date

Hour MinutesAM/PM Option

The Mission of the South Australian Ice Hockey Association Inc is to promote and develop
Ice Hockey as a safe, healthy, and enjoyable sport for all ages and ability levels.