confidential

SAFEGUARDING CONCERN REPORT FORM

Note: * means the field is required before the form can be completed

Person Reporting

First Name

Last Name

Phone Number of Person Reporting

Email of Person Reporting

Are you completing this form on behalf of someone else?

Yes

If yes please state name and role of that individual?

Address of person affected, if known

Telephone number of person affected, if known

Date and time of incident

Name and role of person the safeguarding concern is related to

Is this person aware that this referral is being made

Yes

Nature of safeguarding concern

Please record the nature of incident and what was said / observed in as much detail as possible

Are there any witnesses?

Yes

Names and numbers of witnesses to the incident

Do you give your consent to a member of the England Athletics Safeguarding team and /or UKA Safeguarding to speak to you further about the above incident if need be?

Yes