Incident Report Form

THE SQUASH WALES INCIDENT RECORD FORM

Name of person making referral:
Position of person	Date of referral:
Contact details of person making referral:
Brief outline of reason for referral, giving date and time of incident:
Section A:  Please complete if referral is specifically related to a child/children
Childs name/s	Date of Birth:
Childs address
Parents/carers names and address/es:
Record exactly what child/person referring said.  Continue a separate sheet if necessary.
Actions taken:
Section B:  Please complete if referral is specifically related to a parent/staff member/volunteer in squash
Persons name	Age
Address
Parents address if above named person is under 18.
Club details/county/national details:
Record nature of referral.  Continue of separate sheet if necessary.
Actions taken