EmailMe Form - SAFEGUARDING REFERRAL FORM

SAFEGUARDING REFERRAL FORM

Please use this form to report a safeguarding concern to the Hertfordshire Cricket Safeguarding Team or the Cricket Regulator.

If you have a problem completing this form or would like advice about reporting a concern, please email safeguarding@hertscricket.org or safeguarding@cricketregulator.co.uk providing your contact details so that we can obtain further information from you, if required.

The Cricket Regulator will use the personal information that you provide in accordance with the Cricket Regulator information and privacy agreement (as may be updated from time to time).

In an emergency and/or if you are concerned that someone is at immediate risk of harm, please call the police without delay on 999.

Do not delay in reporting, fill in as much information as you can and send in. Additional information can follow on. The Safeguarding Team will liaise with the Local Authority Designated Officer (LADO) on your behalf.

DATE FORM COMPLETED *
DD / MM / YYYY
PERSON AGAINST WHOM ALLEGATION HAS BEEN MADE
If the allegation is against a member of staff or volunteer, that person should not be informed of the concern until advice has been sought from the Safeguarding Team.
Name *
Date of Birth
DD / MM / YYYY
Role
Coach / Team Manager / Captain / Club Officer / Club Member / etc.,
Organisation / Club Name *
Address
Contact Number
Email
Relationship to child/adult at risk *
Have they been spoken to? *
Yes
No
Account given:
DETAILS OF PERSON COMPLETING THIS FORM
Your Name *
Your Address *
Your Contact No *
Your Email *
*Your Club (if applicable)
Your Role *
SUMMARY OF CONCERN
Name of club / venue / organisation / activity you are concerned about *
Details of the person you are concerned about *
It may relate to a child whose welfare you are worried about or an adult whose behaviour concerns you. Please specify which & include as much personal information as you can.

If you are concerned about a child please include their name, address, date of birth, club details, school, contact details.

If you are concerned about an adult, please also specify their role (player/lead coach/ treasurer/bar staff etc) If your concern relates to more than one person, please be specific about who they are.
Does the person have any specific needs such as any disabilities, mental health issues or additional vulnerabilities *
Please do not give your opinion but provide this information based on factual evidence.
Details of parent/carer (if known/applicable) *
Name
Address
Contact number
Email
Time/location of concern *
If your concern relates to a number of concerns which have come to light over a period of time, then please specify.
When did this incident take place? *
Where did this concern take place? *
DETAILS OF CONCERN
Circumstances:
Please include ALL the information known to you *
Points to cover.
1.What has happened
2. Where did it happen
3. When did it happen
4. Who is involved, and who did what
5. Why did it happen
Try to report in a chronological order. If your information has come to you from a number of individuals, please be clear about who said what Detail any previous concerns about the person you are referring to Include any verbatim comments and the demeanour of the person if possible
Injuries: *
Describe nature of injury, any treatment obtained and by whom
Witnesses: *
Full details of all witnesses to be recorded (Name, address, contact details, role, club) Have they been spoken to? What did they witness?
Action Taken: *
Outline what action has already been taken and by whom
CONFIDENTIALITY
If you have any concerns about approaching a parent / carer please seek advice from the Hertfordshire Safeguarding Team.
Please tell us whether the club has spoken to the child’s parent/carer about the concerns and whether they expressed a view about what should be done.

Do they consent to you sharing this information for the purposes of safeguarding their child? *
ACTION TAKEN
What action has been taken? *
Include things such as:
Did you call Police or Social Services?
Who have you have spoken to about this matter?
Who has been notified (Name and contact details?)
When were they notified?
SUPPORTING DOCUMENTATION
For example: chat logs / social media messages, photos of injuries, notes of conversations, LADO referrals etc
Index of supporting documents provide along with this referral form

PERSON AGAINST WHOM ALLEGATION HAS BEEN MADE

DETAILS OF PERSON COMPLETING THIS FORM

SUMMARY OF CONCERN

DETAILS OF CONCERN

CONFIDENTIALITY

ACTION TAKEN

SUPPORTING DOCUMENTATION