Safeguarding Reporting Form
Please complete the following sections with as much detail about the specific safeguarding concern you have to help us appropriately manage the concerns. A member of the appropriate national safeguarding team will then contact you on the details provided as soon as possible after receiving the completed form; our aim is to respond to all concerns within 5 working days. Please note that should an individual be in immediate danger, or a criminal offence has been committed, please contact the police immediately on 999. To keep children and adults safe, information may need to be shared with appropriate agencies. However, confidentiality will be maintained where appropriate and to ensure that only those who need the information are made aware of it. If you have any queries or need to speak to an individual, please contact the appropriate safeguarding team on:
Welsh Gymnastics:
02920 334978
First Name:
*
Person reporting the safeguarding concern.
This field is required
Surname:
*
Person reporting the safeguarding concern.
This field is required
Phone:
Person reporting the safeguarding concern.
This field is required
Email:
Person reporting the safeguarding concern.
Enter a valid email
Role:
Please Select
Anonymous
Another Sports Organisation
Club member
Club Welfare Officer
Coach
County/Regional Welfare Officer
Other
Other Club Officer
Parent
Peer
Statutory Agency
Unknown
Victim
Please Specify:
Persons Involved
Victim
Person who concerns are for
Adult (18+) or Child?
Adult (18+)
Child
Has adult given consent for referral?
Yes
No
Name of Alleged Victim:
First Name
Surname
Date of Birth:
Phone:
Contact Details for Victim’s Parent/Carer/Appropriate Adult/Personal Assistant
Email:
Contact Details for Victim’s Parent/Carer/Appropriate Adult/Personal Assistant
Enter a valid email
Subject of Concern
Person whose behaviours you are worried about
Name of Subject of Concern:
First Name
Surname
Date of Birth:
Role:
Please Select
Child
Parent
Athlete (over 18)
Coach
Referee/Umpire/Official Other
Anonymous
No Victim
No role
Please Specify:
Sex:
Please Select
Male
Female
Other
Not Specified
Address:
Post Code:
Telephone Number:
Email Address:
Actions already taken:
Are you aware of any local authority /police involvement in this case? If yes, please provide details
Have any of the individual's family or carers been notified of this concern?
Yes
No
If yes please provide details of what was said/action agreed.
Is the Lead Safeguarding Officer aware of this referral?
Yes
No
Details of Concern
Date Occurred:
Time Occurred:
Name of Club:
Where is the club based:
Please Select
Wales
Other
Incident Type:
Please Select
Safeguarding
Equality
Disciplinary
Nature of Incident:
Please Select
Discrimination
Harassment
Victimisation
Category of Concern:
Please Select
Inside or Outside of Sport:
Please Select
July 2020
Occurred in sport
Occurred out of sport
Both
Not known
Describe your concerns:
Include all the relevant information, such as detailed description of your concerns and reasons for these. Please describe any injuries or actions causing concern and whether you are recording these as fact, opinion or hearsay.
Are you reporting your own concerns or responding to concerns raised by someone else?
Please Select
Responding to my own concerns
Responding to concerns raised by someone else
If responding to concerns raised by someone else please their contact information.
Name, Position within the sport or relationshop to the individual concerned, telephone number, email address
Witnesses or Supporting Accounts
Please provide details of any one who has shared your concerns or witnessed any incident: Name, Position within the sport or relationship to the individual concerned, DOB, Address, Postcode, Telephone Number, Email Address
Conflicts of Interest:
Do you have any relationship with anyone involved in this case which could cause a conflict of interest in any investigations? If yes, please describe your relationship
Signature:
Submit
There has been an error, please check the form and try again.
The information you have provided on this form will be used for the purposes of recording your concern. The legal basis for processing this information shall be legitimate interest. The information you provide will be used and stored in accordance with the home nation privacy policy, available on the website below:
Welsh Gymnastics Privacy Policy