Terenure Cricket Club is committed to ensuring that every child, young person and adult involved in cricket within Terenure Cricket Club, whether competitive or social, is treated in an equitable and fair manner regardless of age, ability, sex, religion, social and ethnic background or political persuasion, with respect and dignity, and is safe and protected from all forms of abuse.
Our Child Safeguarding Statement has been developed in line with requirements under the Children First Act 2015, the Children First: National Guidance and TUSLA’s Child Safeguarding: A risk for policy, procedure and practice.
Terenure Cricket Club supports best practice as set out in the “Code of Ethics and Good Practice for Children’s Sport” published by the Irish Sports Council. Terenure Cricket Club, acting through its Committee, shall take all reasonable steps to ensure compliance with the “Code of Ethics and Good Practice for Children’s Sport”.
It is the responsibility of the Terenure Cricket Club Committee to review and update the Statement as required, but as least every 24 months as set out in the Children First Act 2015. The Statement can be revised as required by the Terenure Cricket Club Committee; revisions to the Policy do not have to be voted on by the Members at a General Meeting.
Terenure Cricket Club recognises its responsibility to safeguard the welfare of all children and young people participating in cricket in Terenure Cricket Club by providing a safe and enjoyable environment. Terenure Cricket Club will ensure that all reasonable steps will be taken to ensure unsuitable people are prevented from working with children and young people. To this end, all Coaches and Volunteers working with children within Terenure Cricket Club must be familiar with and agree to abide by the Code of Ethics and Good Practice for Children in Sport and must undergo the Garda Vetting Procedure.
Terenure Cricket Club’s Child Safeguarding Statement includes a Risk Assessment document which indicates the areas of potential risk of harm, the likelihood of harm to a child occurring, and gives the required policy, guidance or process documents to alleviate those risks.
The Risk Assessment was undertaken on 13th March 2018. Terenure Cricket Club recognise that the process of risk assessment associated with Terenure Cricket Club’s activities is both ongoing and dynamic and Terenure Cricket Club is committed to regular review of identified risks and the policies and procedures in place to alleviate those risks.
Signed: _______________________ Date: _____________
Michael Cotter Hon. Sec., signed for, and on behalf of, Terenure Cricket Club
For queries on this Child Safeguarding Statement, please contact the Honorary Secretary at firstname.lastname@example.org.
Codes of Conduct
Child Safeguarding Policy 7
Risk Assessment 8
Disciplinary, Complaints and Appeals Procedures 9
Social Media Policy 9, 10, 11
Use of Mobile Phones Policy 12
Use of Photographic and Filming Equipment Policy 12
Safety Policy 13
Supervision of Children Policy 13
Away Games Policy 14
Changing Rooms and Showering Policy 14
Physical Contact Policy 15
Anti-Bullying Policy 15
Substance Abuse/Drugs Policy 15
Designated Liaison Person 16, 17
Children’s Officer 17
Guidelines for reporting accidents 18
Guidelines for reporting incidents 18
Accident report form 19
Incident report form 20
Parent’s/Guardian’s/Carer’s Code of Conduct
- Do not force an unwilling child to participate in sport.
- Remember children are involved in sport for their enjoyment not yours.
- Encourage your child to play to the rules of the game and not to argue with Umpires/Referees/Officials.
- Teach your child that honest effort is more important than victory so that the result of each game is accepted without undue disappointment.
- Turn losing into winning by helping your child work towards skill improvement and good sportsmanship. Never ridicule or yell at your child, or any other child, for making a mistake or losing a game.
- Remember that children learn best by example. Applaud good play by your team and by members of the opposition.
- Do not question the Umpire’s/Referee’s/Official’s judgement or honesty. Remember he/she is only human with the same feelings as you and, like you, sometimes may make an honest error.
- Support all efforts to remove verbal and physical abuse from sport.
- Recognise the value and importance of coaches who are all volunteers. They give children their time and resources to provide sport for your child.
- Promote Terenure Cricket Club’s Parent’s/Guardian’s/Carer’s Code of Conduct
Player’s Code of Conduct
- Play for the ‘fun of it’, not just to please your parents or coach.
- Play by the Laws of the Game.
- Never argue with the Umpire’s/Referee’s/Official’s decisions.
- Control your temper and use your energies for playing better sport.
- Be a good sport. Recognise all good play, whether by your team or by your opponent’s team.
- Treat all players as you yourself would like to be treated. Do not interfere with, bully or take unfair advantage of any player.
- Remember that the aims of the game are to have fun, improve your skills and feel good.
- Co-operate with your coach, team mates and opponents, for without them you will not have a game.
- Abide by Terenure Cricket Club policy on images.
- Promote Terenure Cricket Club’s Player’s Code of Conduct.
Code of Conduct for Coaches
The following is a code of conduct in relation to child protection, based on the principle that Terenure Cricket Club have a duty of care to safeguard children.
- Respect the dignity and spirit of all players, including children and young adults.
- Treat all players fairly.
- Establish supportive, positive environments to encourage healthy competition, skill development, fun and achievement.
- Avoid contact or conduct that may be interpreted as having sexual connotations or inappropriate behaviour.
- Do not take part in or tolerate behaviour that frightens, embarrasses or demoralises a player or negatively affects their self esteem.
- Do not tolerate acts of aggression, harassment or abuse.
- Be prepared to intervene if a child or young person is being abused or neglected and record and report to Children’s Officer or Designated Liaison Person.
- Practice fair play both during and outside of all sports activities. “Fair Play” is defined as showing considerate regard for players, leaders, parents, spectators and officials, abiding by the rules and accepting official’s decisions.
Spectator’s Code of Conduct
You are very welcome to Terenure Sports Club. We hope you enjoy your visit and the game you have come to see. We ask you to abide by our spectators code of conduct during your visit.
- Remember that children play organised sports for their own enjoyment. They are not there to entertain you.
- Be on your best behaviour. Do not use profane language or harass, physically or verbally, players, coaches, umpires, referees or other officials.
- Applaud all good play by your own team and the other team.
- Show respect for your team’s opponents. Without them, there would be no game.
- Never ridicule or scold a child for making a mistake during a game.
- Condemn the use of violence and verbal abuse.
- Respect the Umpire’s/Referee’s decisions. Remember they are only human with the same feelings as you and, like you, sometimes make an honest error.
- Encourage players to always play fairly.
Child Safeguarding Policy
Terenure Sports Club Policy is to ensure that the best practice is followed by Terenure Cricket Club as set out in the Child Safeguarding Statement. In order to promote best practice, Terenure Cricket Club shall comply with the Guidelines of the Code of Ethics and Good Practice for Children’s Sport which are:
- To adopt and implement the Code of Ethics and Good Practice for Children’s Sport as an integral part of Terenure Cricket Club’s policy on children’s wellbeing within Terenure Cricket Club.
- To promote the interests of the child within Terenure Cricket Club including through meetings and AGMs.
- To adopt and consistently apply a safe and clearly defined method of recruiting and selecting Sports Leaders.
- To appoint at least one Children’s Officer.
- To have a Designated Liaison Person to act as liaison with the Statutory Authorities in relation to the reporting of allegations or suspicions of abuse.
- To have in place procedures that follow best practice for dealing with a concern or complaint against a Sports Leader, or Children’s Officer or other Member of Terenure Cricket Club.
- To ensure that the Sports Leaders report to the Youth Sub-Committee and/or the Committee.
- To have in place effective procedures for responding to and recording incidents.
- To ensure that any unusual activity is reviewed, investigated if necessary and reported to a Children’s Officer, Designated Liaison Person or Committee Member.
All persons involved in Terenure Cricket Club have a responsibility to:
- Refrain from any inappropriate behaviour towards children or vulnerable adults
- Avoid situations which could give rise to allegations of inappropriate behaviour or abuse.
- Report disclosures, suspicions or concerns of abuse that relate to children or vulnerable persons.
It is Terenure Cricket Club’s policy to support the Children’s Officers and Sports Leaders through education and training to be aware and understand best practice.
All persons involved in Terenure Cricket Club that witness, suspect or have concerns of inappropriate behaviour or abuse, must take action and report the incident or suspected abuse to the Designated Liaison Person.
Terenure Cricket Club shall minimise in as far as reasonable, the risk of harm to children and vulnerable adults during the activities of Terenure Cricket Club.
Terenure Cricket Club shall ensure that persons working with children and who have substantial access to children in Terenure Cricket Club have appropriate qualifications and clearances.
Procedures in place to manage risk
including but not limited to
Policy not communicated properly
Risk not recognised
The Training procedure in conjunction with the Social Media Policy
Children in open competitions
Club and coaching practices
Injury, risk not recognised
Unknown people and environments at home and away games
Travel to away games
Club and coaching practices
Away Game Policy
Late collection of children
Club and coaching practices
Children going home without permission
Complaints and discipline
Policy not known / implemented
Use of facilities
Inadequate supervision/ Inappropriate behaviour
Changing Rooms Policy
Club and coaching practices
Harm by adult or other children
Physical Contact Policy
General risk of harm
Harm by adult or other children
Risk not reported
Disciplinary, Complaints and Appeals Procedures
Terenure Cricket Club, its Officers and its members shall be bound by the reporting procedures as set out by legislation. Terenure Sports Club disciplinary, complaints and appeals procedure set out in Terenure Sports Club Constitution shall apply in addition to any applicable statutory requirements
Social Media Policy
Terenure Cricket Club recognises that social media provides an effective platform for discussion and information sharing amongst adult and youth club members together with the wider community. Terenure Cricket Club wishes to promote and encourage the positive use of social media platforms by all members for the benefit of Terenure Cricket Club.
Nevertheless, Terenure Cricket Club also recognises that the use of social media can pose risks to Terenure Cricket Club, our reputation, our requirement to comply with legal obligations as well as to individual members. One inappropriate comment can cause distress to one person and impact hundreds of others. The purpose of this policy is to protect Terenure Cricket Club members, minimise risk and ensure Terenure Cricket Club’s social media is used appropriately.
Guidelines for Social Media Posts
- Posts on Terenure Cricket Club’s social media or media linked to Terenure Cricket Club’s social media, be it photos, comments or links should not be inappropriate.
- Users must not engage in activities or transmit content that is harassing, discriminatory, menacing, threatening, obscene, defamatory, or, in any way objectionable or offensive.
- Users are personally responsible for what they communicate on social media and should remember that what they publish may be available to a wide audience over a lengthy period of time.
- Users should not post comments which could be construed as sensitive, objectionable or inflammatory.
- When using social media, users should respect their audience.
- Users should not engage in any inappropriate chat with members.
- Users should not criticise a player’s performance or skill development or make a personal attack on any player, umpire, official club or any other person or body which could bring the game or Terenure Cricket Club into disrepute.
- Inappropriate, derogatory or defamatory remarks or unseemly language should never be used
Anyone who finds a post inappropriate or wishes to make a complaint should e-mail details to the Club Chairman and/or Hon. Secretary at email@example.com
- Comments that are deemed to breach the guidelines above will be removed by the administrators and the person who posted will be informed.
- Destructive or negative uses will be deleted and users blocked from engaging with the club’s Facebook page, Twitter account or Website. Any Terenure Cricket Club member who persistently posts inappropriate content will be dealt with by the Club’s disciplinary subcommittee.
- The Club Designated Liaison Person will be informed of any matters relating to young or vulnerable people and deal with the post as appropriate.
- Issues relating to adults and the reputation of Terenure Cricket Club will be referred to the Terenure Cricket Club Committee who may refer to matter to the Club’s disciplinary subcommittee.
- There may also be additional sanctions imposed on the Club/member by Cricket Leinster and Cricket Ireland.
Controls over Club Specific Social Media
Terenure Cricket Club uses a Twitter account @TerenureCC, Facebook page https://www.facebook.com/TerenureCricketClub, Instagram account @TerenureCC and Website https://www.terenurecricketclub.com to represent Terenure Cricket Club to the outside world, catering for members and prospective members as well as providing information for other clubs and general browsers seeking knowledge about
Terenure Cricket Club. Terenure Cricket Club may add additional social media platforms from time to time.
Material published on these mediums is strictly controlled by members of the Terenure Cricket Club Committee.
- The Terenure Cricket Club Committee authorises certain individuals involved in key roles within the Club to post on these social media platforms.
- Comments and photos/videos posted will feature positive club news and events.
- Personal information about members will not be disclosed.
- No statements will be made that are misleading, false or likely to injure the reputation of another person/club.
Implications for Young People
The Cricket Ireland Child Safeguarding Manual (CI Child Safeguarding Manual) and the Club’s Child Safeguarding Statement provide the relevant guidance to communicating with young or vulnerable people.
The key Do’s and Don’ts when communicating with young people are:
- contact players only when necessary
- copy parents into written communication (i.e. letters or emails)
- speak with a player and their parents if there is a need to communicate information in relation to playing, training or competition
- clearly state the club’s policy on communication with players and parents.
Contacting young people by phone, text, e-mail or a social networking site should never be undertaken without parental consent.
- contact a young person unnecessarily
- e-mail, text, or contact via a social networking site, one young person without copying in parents, other players or club members
- make or receive calls on a mobile phone during training or at competition. It is inappropriate to compromise the safety of a session
WhatsApp is a popular instant messaging app, which lets you send messages, images and videos to friends. You can have 1-1 conversations as well as group chats. The app is being increasingly used by Club members as a useful communication tool. This clause recognises that WhatsApp is being used with young persons and provides guidance on good practice for using the app.
- Have an adult (Captain/Coach or Manager) set the group up (allowing admin rights)
- Ensure the group has at least 2 adults
- Tell participants what the app is/isn’t to be used for
- Inform parents of its intended use
- Get the participants to agree how the app is to be used i.e. only Cricket orientated content
- Keep language appropriate
- Ensure members have a mechanism to report inappropriate content
- Assume everyone is on WhatsApp
- Use the app for private messaging
- Use the app to replace formal feedback
- This guidance should be applied to all equivalent social media/group communication apps.
Use of Mobile Phones Policy
Terenure Cricket Club acknowledges the significant impact that communications and social media technologies have for all Members including children, and because of various formats available, Terenure Cricket Club encourages that they are used safely, sensibly, securely and responsibly at all times for their positive benefits and to minimise the potential negative or harmful uses for which they can be used. Terenure Cricket Club policy on mobile phones is as follows:
- To ensure that mobile phones are stored with personal possessions during the activities of Terenure Cricket Club.
- To ensure the appropriate use of mobile phones in changing rooms and other private areas.
- To ensure that camera phones are used safely and responsibly.
- Where photos are being taken, that Terenure Cricket Club policy in relation to photographs and images are strictly adhered to. All communications by Sports Leaders and Children’s Officers by text, email, websites and social media should follow the guidelines for use of such communications.
Use of Photographic and Filming Equipment Policy
It is Terenure Cricket Club’s policy to ensure that photographers, operators of film and video equipment and all other devices for making images, do so in line with good practice with Child Safeguarding policies and avoid the use of zoom close-up and repetitive images; this is to avoid the risk of inappropriate unsolicited attention from persons within and outside Terenure Cricket Club. The Policy with regard to use of images applies to all Members, Officers, Parents/Guardians or other persons associated with Terenure Cricket Club and is intended to protect all persons associated with Terenure Cricket Club. Any person associated of Terenure Cricket Club who is concerned about photography taking place should contact the Designated Liaison Person.
Coaches, Managers have a responsibility to ensure the safety of the children whom they coach or manage especially in any Open Competitions (i.e. adult games). It is Terenure Cricket Club’s policy that the Club Selectors consider all relevant factors including but not limited to the age, maturity and ability of any child before a decision is made to allow or otherwise such child to play in open competitions. The Club is committed to ensuring that the Captain, Coaches and Managers as applicable take the following safety measures when children are playing in such games.
At every game, the Captain, Coach or Manager will do the following:
- ensure any necessary protective gear has been brought by all players
- implement safety requirements by ensuring that all children are wearing the appropriate helmets, bowling restrictions and fielding restrictions
If an incident occurs, either at an away game or a home game, the Captain, Coach or Manager must:
- arrange for the child to be taken to a local hospital or doctor if required
- contact the player’s parents and keep them informed of all details
- make a brief record of injury and action taken
- make a brief record of the problem/action/outcome
Supervision of Children Policy
Terenure Cricket Club will ensure that when children are attending training at the Club or are travelling to and from away games or are playing at home games, the following steps will be taken by Coaches and Managers and Volunteers with regards to the supervision of children during such times:
- An adequate adult: child ratio is maintained. Recommended ratio is 1:8 under 12 and 1:10 over 12. This will depend on the nature of the activity, the age of the participants and any special needs of the group.
- Where there are mixed groups, there should be leaders of both genders.
- Avoid being alone with one child.
- If there is a need to talk separately to one child, do so in an open environment in view of others.
- Communicate in writing in advance the start and end of coaching sessions.
- Two people (either Captains, Coaches, Managers or Volunteers) should stay until all children have been collected.
- Keep an attendance record of all children.
- Comply with all other policies and procedures set out in the Terenure Cricket Club Child Safeguarding Statement.
Away Games Policy
Terenure Cricket Club acknowledges that there is extra responsibility to be taken on by Coaches, Managers and Volunteers when they travel with children to away games. When travelling to away games, the Coach/ Manager/ Volunteers should do the following:
- communicate in advance of any away game in writing with all parents with regards to provision by them of food and water for their children for the trip, travel times, location of the game and notify them of the timing of the end of the game.
- ensure that anyone transporting children in their cars should be aware of the extent and limits of their motor insurance cover particularly in relation to acceptable numbers and liability
- alternate drivers if possible and which child is dropped off last/ collected first
- inform parents that they can download the Sport Ireland’s Safeguarding App as one of the features of the App is a “Travel Tracker” function which will allow them to have oversight of their journey to and from the away game
- if travelling by car, not carry more than the permitted number of passengers
- ensure the use of safety belts
- avoid travelling alone with one child
- if travelling by car, put children in the back seat
- arrange central collection points
- all children are supervised at all times at the location of the away game and no child should be allowed to leave such venue
- ensure the Club’s Policy on Supervision is complied with at the away game venue
Changing Rooms and Showering Policy
The Club acknowledges that the changing room is a place for the members to change clothes (and shower) in privacy. The Coaches, Managers and Volunteers must comply with the following steps with regards to changing rooms:
- Only Coaches, Managers and players of a team may enter the changing rooms before, during and after a match.
- No Coach, Manager or Volunteer may enter a showering room while players are showering.
- Parents should be made aware that adults may be changing at the same time as children and any concerns that they may have should be passed on to the Terenure Cricket Club Committee.
- If any children are uncomfortable changing or showering at the Club, no pressure should be put on them and they can change at home if they prefer.
Physical Contact Policy
All Coaches, Managers and Volunteers will ensure that they do the following at all times when coaching/ managing/ supervising children who are members of Terenure Cricket Club when they are attending training sessions or playing in home or away games for the Club:
- avoid unnecessary physical contact
- any necessary contact should be in response to the needs of the child and not the adult
- physical contact should be determined by the age and development stage of the child.
- ·never engage in inappropriate touching
Terenure Cricket Club is committed to ensuring that no Member is subjected to physical, emotional, psychological, verbal or cyber aggression that is conducted by a Member or a group of Members, or other persons associated with Terenure Cricket Club and is deliberately hurtful. All members should be able to enjoy the activities of Terenure Cricket Club free from bullying, abuse and harassment. Terenure Cricket Club’s policy is to provide an environment which is free from actions that are intentionally aggravating or intimidating behaviour to an individual; this includes teasing taunting, threatening, hitting or extortion by one or more Members against an individual. For the avoidance of doubt this applies not only to actions during the activities of Terenure Cricket Club but also to any actions by a Member or Members or other persons associated with Terenure Cricket Club that may restrict a Member’s involvement and enjoyment in Terenure Cricket Club. All forms of bullying are considered unacceptable including physical, emotional, psychological, verbal or cyber bullying: bullying based on racism, ethnic background, religious background or sexual orientation is unacceptable. Terenure Cricket Club expects all Members or other persons associated with Terenure Cricket Club to report any incidence of bullying or a suspected incidence of bullying to a Sports Leader or Children’s Officer or to another appropriate person.
Substance Abuse/Drugs Policy
It is Terenure Cricket Club’s policy to comply with the international, national and provincial bodies’ policies on substance abuse. The use of drugs is actively discouraged as being incompatible with a healthy approach to sporting activity.
It is Terenure Cricket Club’s policy to promote fair competition through development of sound training practice and discourage the use of any substance that is perceived to offer short cuts to improved performances or to by-pass the commitment and hard work required to achieve success.
Designated Liaison Person
- The Designated Liaison Person shall have knowledge of the Code of Ethics and the Plan, this Child Safeguarding Statement, the Children First Act 2015, the “Our Duty to Care” document covering The principles of good practice for the protection of children and young people as prepared by the Department of Health & Children and the Cricket Ireland Child Safeguarding Manual.
- The Designated Liaison Person shall be encouraged to make recommendations to the Committee regarding the updating of the Child Safeguarding Statement and its implementation.
- The Designated Liaison Person shall recognise the responsibility of the Statutory Agencies in dealing with reportable incidences.
- The Designated Liaison Person shall keep records of incidences that are not reported and the actions taken as a result of the concerns or allegations brought to his or her attention.
- When for any reason the position of the Designated Liaison Person is not filled, the role shall be filled by the Chairman of the Club or other appointed Club Officer until the position is filled.
- The Designated Liaison Person’s duties and responsibilities shall include those set out for the Mandated Person in the Children First Act 2015 .
- Key sections of the Children First Act 2015 are set out below as they form part of the reporting procedure.
Note that Section 14 of the Children First Act 2015 states that:
“Subject to subsections 3, 4, 5, 6 and 7, where a mandated person knows, believes, or has reasonable grounds to suspect, on the basis of information that he or she has received, acquired or becomes aware of in the course of his or her employment or profession as such a mandated person, that a child (a) has been harmed, (b) is being harmed, or (c) is at risk of being harmed, he or she shall, as soon as practicable, report that knowledge, belief or suspicion, as the case may be, to the Child and Family Agency”.
Section 14 (2) states that:
“Where a child believes that he or she (a) has been harmed, (b) is being harmed, or (c) is at risk of being harmed and discloses that belief to a mandated person in the course of the mandated person’s employment or profession as such a person, the mandated person shall, subject to subsections 5, 6, 7 as soon as practicable, report that disclosure to the Child and Family Agency”.
Section 14(6) states that:
“Subject to subsection 7, a report under subsection 1 or 2 shall be made by the completion such form as shall be specified for that purpose by the Agency( in this Act referred to as a “ mandated report form”) and may be made by the mandated person(a) himself or herself, or (b) jointly with one or more than one other person, irrespective of whether or not the other person is a mandated person”
“Where a mandated person action in the course of his or her employment or profession knows, believes or has reasonable grounds to suspect that a child may be at risk of immediate harm and should be removed to a place of safety, he or she may make a report to the Child and Family Agency under subsection (1) or (2) other than by means of a mandated report form”.
The name of Designated Liaison Person shall be made known to all in Terenure Cricket Club. He/She is the person to whom Child Safeguarding concerns will be addressed. If the concern is about the Designated Liaison Person, please report to a member of Terenure Cricket Club Committee.
Terenure Cricket Club has procedures in place for dealing with concerns or allegation of abuse or neglect either within Terenure Cricket Club or externally but the first point of contact for the child, parent/guardian or coach is the Designated Liaison Person. However, any individual has the right to contact Social Services or An Gardaí directly if they have concern about a child’s welfare.
The Designated Liaison Person within Terenure Cricket Club is:
Name: Kenny McDonald
Club Children’s Officer
The Children’s Officer is the link between youth mentors, members and the Executive Committee. It is essential that this communication line is clear and working. The Children’s Officer may be assisted by others whose details are prominently displayed in e.g. club changing rooms, offices, and pavilion. The Children’s Officer’s function is to engender a child-centred club ethos, promote ethics and good practice, influence club policy and report to the Committee and Designated Liaison Person.
The Children’s Officer (CO) within Terenure Cricket Club is:
Name: Madeline Lynch
Telephone number: 087 961 9322
Guidelines for Reporting Accidents
In the event of an accident the following procedure will be followed:
- Contact parents/guardians in the event of all accidents.
- Fill in 2 copies of the Accident Form for ALL accidents. One copy to incident book/folder, other to Designated Liaison Person for filing/further action.
- For more serious accidents:
- Contact emergency services/G.P. if necessary
- Record detailed facts surrounding accident, witnesses etc.
- Complete accident form/book as above
Guidelines for Reporting Allegations/Incidents
- Record all incidents reported or observed on an incident form, forward to the Designated Liaison Person.
- Ensure confidentiality – a ‘need to know basis’
- The Designated Liaison Person is responsible for report security
Accident Report Form
Coach/Manager in attendance: ____________________________
Name: ____________________________ D.O.B:_____________
Parent’s Contact Number: __________________
Date: ______________ Time: _______________
Nature of injury: ___________________________________________
How it happened: ___________________________________________
First Aid Involved: Yes/No
Medical Attention Sought: Yes/No
Parent informed: Yes/No By whom: __________________
Referred to Designated
Liaison Person: Yes/No
Form completed by: _____________________________
Incident Report Form
Child’s Name: ____________________________ D.O.B. _____________
Child’s Address: _________________________________________
Parent’s/Guardian’s Name: _________________________________
Date: ______________ Time: _______________
What did the _______________________________________________
child say? _______________________________________________
What did you _______________________________________________
say to the child?_______________________________________________
Actions taken _______________________________________________
so far: _______________________________________________
Name: ________________________ Position: __________________
Signed: ________________________ Date: ______________
Do not discuss this incident with anyone other than those who need to know. This form should be completed with as much detail as is known and returned
marked “Confidential” to the Designated Liaison Person. Continue on a blank sheet where appropriate.