Incident and Concern Reporting Form
If a child or young person is in immediate danger, call 000 first. Complete this form as soon as it is safe to do so.
1. Your Details (the person making this report)
I wish to remain anonymous (this will limit the Club's ability to investigate or respond)
Full name
First Name
Last Name
Email address
example@example.com
Mobile number
Format: 0000 000 000.
Date of this report
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Your relationship to the Club (select one):
Parent/Guardian
Swimmer
Coach/Official
Volunteer
Committee
Other
2. What is your concern about? (select all that apply)
Nature of the Concern
Child safety concern
Behavioural or Code of Conduct matter
Integrity matter (doping, competition manipulation, discrimination, harassment)
Other (please describe below)
If "Other", please describe
Is there an immediate safety risk to a child or young person right now?
Yes
No
If you selected "Yes" above
Call 000 (Police/Ambulance) now, if you have not already.
Then contact the Child Safety and Governance Lead, or the President if the Child Safety and Governance Lead is unavailable, as soon as it is safe to do so.
Back
Next
3. Who is involved?
Name
First Name
Last Name
Role (swimmer / coach / official / volunteer / parent)
Name
First Name
Last Name
Role (swimmer / coach / official / volunteer / parent)
3. Who is involved?
Date of incident/concern
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Approximate time
Hour Minutes
AM
PM
AM/PM Option
Location
What happened? Please include as much detail as you can (what was said or done, and by whom)
Names of any witnesses
5. What would you like the Club to do?
What response or outcome would you like to see from the Club?
6. Your Confirmation
I confirm that the information provided in this form is true and accurate to the best of my knowledge. I understand that the Club will handle this report in accordance with the Complaints and Participant Protection Policy, and that confidentiality cannot be guaranteed where the law requires disclosure (e.g. mandatory reporting).
Signature
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
OFFICE USE ONLY
Received by
First Name
Last Name
Date received
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pathway (circle one): Child safety (Section 9) / Integrity referral / General (Section 7)
Referred to / filed in register
Preview PDF
Submit
Should be Empty: