THE GWENT COUNTY FOOTBALL ASSOCIATION SG1 Safeguarding Incident Referral Form RELATING TO CHILD PROTECTION OR POOR PRACTICE
Section 1: YOUR DETAILS
Name:	Click or tap here to enter text.
Address:	Click or tap here to enter text.
Email address:	Click or tap here to enter text.
Telephone Number:	Click or tap here to enter text.
Club:	Click or tap here to enter text.
Section 2: YOUR REFERRAL
Please provide a brief description of the incident or concerns and what prompted this referral (please include times, dates, location and other relevant information, including whether you are recording fact, opinion or hearsay): Click or tap here to enter text.
Information contained on this form will form part of the GCFA’s investigation to the alleged incident and assist the GCFA to take whatever action that it deems appropriate. As the person completing this form, please be aware that you must notify each individual whose details you include on this form that this information may be shared with a number of organisations and individuals, such as relevant Club / League / Area or Governmental Authorities (however not if it may aﬀect the prevention or detection of a crime or the prosecution of an oﬀender). Your Signature: Click or tap here to enter text. Date: Click or tap to enter a date. IMPORTANT Please remember to maintain conﬁdentiality and only disclose information on a need-to-know Basis; do not discuss with anyone other than those who need to know. Only share information if it will protect the child. If your concerns relate to poor practice, please forward a copy of this form to your Area Safeguarding Oﬃcer (details in your handbook), even if the club has sought a resolution to the matter. If your concerns relate to suspected abuse, please forward a copy of this form directly to the Gwent County Football Association, as soon as practically possible. Please mark “Private & Conﬁdential” and return to GCFA Safeguarding - safeguarding@gwentfa.co.uk. Please also ensure you keep a copy for your reference as well as other notes taken. If the incident / concerns refer to more than one child please complete a separate GCFA Safeguarding Incident Referral Form, attach together, and submit with any other relevant information, stating the page number below.