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ISA Safaeguarding Report Form

HomeISA Safaeguarding Report Form

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- ISA Safeguarding Policies
- ISA Safaeguarding Report Form
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IVERSON SPORTS ACADEMY - SAFEGUARDING CONCERN REPORT FORM

This form is to be completed by any individual who has a concern about the safety or welfare of a child (under 18 years of age) involved with Iverson Sports Academy.

Please complete all sections as accurately and factually as possible. Do not include opinions or assumptions.

SAFEGUARDING CONCERN REPORT FORM

1. Details of the Child/Young Person:

Full Name of Child

Date of Birth

Gender

Male

Female

Known Address

Parent(s)/Guardian(s) Name(s)

Parent(s)/Guardian(s) Contact Number(s)

Team/Age Group at Iverson Sports Academy

2. Details of the Child/Young Person:

Your Full Name

Your Relationship to the Child (e.g., Coach, Volunteer, Parent, Child, Other)

Your Contact Number

Your Email Address

Date of Report

3. Nature of the Concern:

Date(s) and Time(s) of Incident/Disclosure (if known):

Location of Incident/Disclosure (if known)

Please describe the concern in detail, including what you saw, heard, or were told. Use clear and factual language. (Continue on a separate sheet if necessary)

Did the child disclose this information to you?

Yes

No

If yes, please record the child's exact words if possible

Are there any other witnesses to the incident or disclosure?

Yes

No

If yes, please provide their names and contact details (if known)

Have you spoken to anyone else about this concern?

Yes

No

If yes, who and when?

Do you believe the child is at immediate risk of harm?

Yes

No

If yes, have you contacted the police?

Yes

No

If yes, please provide details (e.g., name of contact person, time of call)

4. Action Taken (if any):

What immediate actions did you take (if any) when the concern arose?

5. Your Understanding and Declaration:

I understand that the information provided in this report will be shared with the Designated Safeguarding Officer (DSO) and potentially other relevant authorities on a need-to-know basis to ensure the safety and well-being of the child.

I confirm that the information provided in this report is, to the best of my knowledge, accurate and factual.

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support@iversonsa.co.tz

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