Incident Report Form
welfare@girlsunitedfa.org
Your details
Your full name
First Name
Last Name
Your role or relationship to Girls United:
Your contact email:
example@example.com
Your phone Number:
Format: 0000000000.
Incident Details
Name of person in question
First Name
Last Name
Name of Girls United staff in charge of activity
Location of incident
Date of Incident
-
Day
-
Month
Year
Date
Hour Minutes
Which of the following best describes the person you are concerned about?
Please Select
Player
Parent
Spectator
Coach
Staff
Volunteer
Other
OPTIONAL: Contact information of person – If underage, please include name of contact and relationship to person
Phone number, email address and/or address.
Type of Incident
Safeguarding Report
Accident or Injury Report
No incident but raising a concern
Other
Nature of Incident
Please describe in one sentence
Give details of how and precisely where the accident took place
Describe what activity was taking place, e.g. training programme, getting changed, etc.
Location(s) of injury
e.g. "cut on right elbow, about the size of a £1 coin"
Give details of the action taken, including any first aid treatment and the name(s) of the first aider(s),
Please record any First Aid equipment/materials used:
If you noticed low stock of any equipment or material, please also include in response.
Where any of the following contacted?
Police
Abulance
Parent/ Guardian
Girls United Staff
Other
What happened to the injured person after the accident?
e.g. went home, went to hospital, carried on with session
Give details of precisely what took place:
Please state facts on what you saw or heard
What actions did you take?
Please share any additional details on why you are concerned
Your professional opinion on the matter, anything said by others or witnesses
When did you last see or have contact with the person you are concerned about?
How long have you had concerns?
Please Select
Happening now or today
A week
A month
Six months
A year
Non recent / No longer happening
Not disclosed / Not Known
Where any of the following contacted?:
Police
NSPCC
Girls United Staff
Parent / Guardian
Other
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All of the above facts are a true and accurate record of the incident.
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Follow Ups
Please share all information on follow-up: General
Please include dates of different submissions if applicable.
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Status
Please Select
Initial Submission
Follow-up Stage
Closed
Full name:
First Name
Last Name
Should be Empty: