Safeguarding Report Form

Thank you for reporting a safeguarding concern to us. We will review the information you submit and investigate every report that is sent in to us.

About You

Reporter's Name

Please provide your details, as the person who is reporting poor practice

Reporter's Telephone Number

Please confirm your details. We may need to contact you about the incident

Your Role in Football

Please confirm your role. If your role is not listed, please select "other"

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Reporters Email Address

Please confirm your details. We may need to contact you about the incident.

Check if you wish to remain anonymous

Name of Person you are Reporting*

This is the name of the person you are reporting. If you are unsure of their name please state "unknown".

What is this persons role in football?

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What organisation is this person associated with?

Please enter the club or organisation name

When did the incident take place?

Please identify the date of when the incident took place

Where did the incident take place?

Please provide the location of the incident i.e. location of match or training session, ground name, post code ect

Did you personally witness the incident?

Please indicate whether you witnessed the incident yourself or whether it was reported to you

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Please explain what happened

Please provide as much detail as possible regarding the poor practice referral

Do you have any Evidence to support this?

Please select all that apply

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File Upload

Drag and drop files here or

Are you happy for this evidence to be disclosable?

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Have you made a referral to any of these bodies?

Other than ourselves at Leicestershire & Rutland CFA, have you reported this incident to anyone else? Please select all that apply

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Send me a copy of my responses