(Appendix c)
INCIDENT REPORT FORM

Name of Child: ………………………………………… Date of Birth: ………………………..
Address: ……………………………………………………………………………………………
…………………………………………………………………………………………………………
……………………………………………………………… Post Code: ………………………….
Date: ………………. Time: ………………….. Place: …………………………………………
What the child has said (in their own words):

Observations (of person incident reported to):

Any action that has been/or is to be taken:

Name: ………………………………………Signature:…………………………………
Other Club member present:…………………………………………………………………