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Incident Reporting Form
Please use this form to report any injury accidents, incidents, near miss events or safeguarding concerns. Anyone can complete this form, we take all reports very seriously and will attempt to resolve all reported concerns as soon as possible. Please help us by providing as much detail as possible.

We will keep information reported confidential, only sharing details when we are required to report an incident (such as child related abuse), or if we believe it is in the best interests of all parties concerned.

If you would like to speak to a Dursley Running Club Safeguarding Officer directly they are; Caroline Jones, Annette Keevil, Chris Sweet and Nicky Grant. They can be contacted directly or via the DRC Junior email address; (dursleyrunningclubjuniors@gmail.com).

Email address *
Full name of person completing the report: *
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Contact details in case we need further information, or so that we can let you know what action was taken if appropriate: *
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If this report concerns others please tell us who this report concerns:
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Date of incident: *
MM
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DD
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YYYY
Time of incident (if known):
Time
:
Location of incident (if known):
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Please describe the incident, providing as much detail as possible (if this is a child disclosure record details in the child’s words where possible): *
Your answer
Please describe any action taken/treatment given (including details of any official or agency contacted):
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Please record any further actions required or recommendations, if appropriate, to replace supplies or prevent reoccurrence:
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A copy of your responses will be emailed to the address you provided.
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