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

 

 

 

 

 

 

 

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