Online Disciplinary/Safeguarding Report Form

Please complete the following sections with as much detail about the specific complaint, safeguarding concern or allegation as soon as possible. British Wheelchair Basketball’s Lead Safeguarding officer will contact you as soon as possible after receiving the referral, however if a child or adult is in immediate danger or a hate crime has been committed, please contact the police, social care services or the NSPCC immediately. To keep children and adults safe, information may need to be shared appropriately with other entities*. 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 concerns about the information you are providing, please contact British Wheelchair Basketball’s Lead Safeguarding Officer on 01509 279900 / safeguarding@britishwheelchairbasketball.co.uk.

First Name: * Person reporting the safeguarding concern.

Surname: * Person reporting the safeguarding concern.

Phone: Person reporting the safeguarding concern.

Email: Person reporting the safeguarding concern.

Role:

Persons Involved

Victim

Person who concerns are for

Adult (18+) or Child?

Adult (18+)

Child

Has adult given consent for referral?

Yes

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

Subject of Concern

Person who concerns are about

Name of Subject of Concern:

First Name

Surname

Date of Birth:

Role:

Sex:

Address:

Post Code:

Telephone Number:

Email Address:

Have any of the individual's family or carers been notified of this concern?

Yes

If yes please provide details of what was said/action agreed.

Is the Lead Safeguarding Officer aware of this referral?

Yes

Details of Concern

Are you reporting your own concerns or 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

Date Occurred:

Time Occurred:

Name of Club:

Incident Type:

Category of Concern:

Inside or Outside of Sport:

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.

Actions already taken: Are you aware of any local authority /police involvement in this case? If yes, please provide details

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, plase describe your relationship

Signature:

*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 British Wheelchair Basketball's privacy policy, available at www.britishwheelchairbasketball.co.uk/mdocs-posts/data-privacy-notice/