Safeguarding Referral Form.

Please use this form to report a safeguarding concern to the ECB.

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

After submitting your concern, you will receive an automated email with a unique reference number please keep a record of this. The ECB will use the personal information that you provide in accordance with the ECB 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 ECB Safeguarding Team will liaise with the Local Authority Designated Officer (LADO) on your behalf.

Details of person completing this form.
Name
Address
Contact number
Email address
Club (if applicable)
Role

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/barman 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 Where did it happen When did it happen Who is involved, and who did what 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

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?

If you have any concerns about approaching a parent / carer please seek advice from the ECB Safeguarding Team.

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 ECB Safeguarding Team.
Name
Date of birth
Role
Address
Contact number
Email address
Relationship to child / adult at risk.
Have they been spoken to? Yes / No
Account given.
Action 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?