Safeguarding - Rhyl Rugby Club

Your Name *

Your Email Address *

Your Phone Number *

Your role during the incident *

What date and time did the incident occur? *

Date

Time

Location of incident (venue and address) *

Club / Organisations involved *

Persons Involved

How many people were involved in the incident that you would like to include? *

1
2
3
4

role exact witness

Person 1

Please provide: full name, age / date of birth, role (player, coach, parent etc), contact details (if known)

Person 2

Please provide: full name, age / date of birth, role (player, coach, parent etc), contact details (if known)

Person 3

Please provide: full name, age / date of birth, role (player, coach, parent etc), contact details (if known)

Person 4

Please provide: full name, age / date of birth, role (player, coach, parent etc), contact details (if known)

Description of incident

Please provide as much detail in a factual way as possible. I appreciate that emotions and perceptions arise during incidents. Please keep to a clear factual account without personal judgements and opinions on the incident. This is not to disregard your feelings on the matter, this is also very important, just please try to list the information as factually as possible.

Please provide a clear, factual account of what happened. Include what you saw or were told. Use exact words where possible. *

Immediate Actions Taken (Describe what you or others did at the time in response to the incident, again a clear and factual account.) *

Current Safety/Welfare Is the individual currently safe? Are there any ongoing concerns or risks? What are your safeguarding concerns? *

Witness Details Name: Contact Details: What they observed (if known): Please include any appropriate witness details and request that they also complete a form. *

Previous Concerns (if any) include any relevant previous incidents or concerns

Declaration

I declare that this statement is a true and accurate account of the incident to the best of my knowledge. *

Yes
No