FAI Online safeguarding Concern Report form

Please complete the following sections with as much detail about the specific safeguarding concern or allegation as soon as possible. A member of the FAI Child Welfare & Safeguarding Department will contact you as soon as possible after receiving the referral, however if a child or Vulnerable person (adult) is in immediate danger, please contact the An Garda Siochana, or TULSA immediately. To keep children and Vulnerable Persons (adults) safe, information may need to be shared appropriately with other entities*. However, confidentiality will be maintained where appropriate and to ensure that only those who need the information are made aware of it. For lower level concerns complaints or concerns please ensure you have following all necessary stages set out in the concern-complaint procedure prior to escalation to the FAI. If you have any queries or concerns about the information you are providing, please contact The FAI Child Welfare and Safeguarding Department at Childwelfare@fai.ie

First Name: * Person reporting the safeguarding concern.

Surname: * Person reporting the safeguarding concern.

Phone: Person reporting the safeguarding concern.

Email: Person reporting the safeguarding concern.

Role:

Persons Involved

Child Subject of Harm or Vulnerable Person (Adult) Subject of Harm

Person who concerns are for

Adult (18+) or Child?

Adult (18+)

Child

Has adult given consent for referral?

Yes

Name of Alleged Child Subject of Harm or Vulnerable Person (Adult) Subject of Harm:

First Name

Surname

Date of Birth:

Phone: Contact Details for Child Subject of Harm’s Parent/Carer/Appropriate Adult/Personal Assistant

Email: Contact Details for Child Subject of Harm’s Parent/Carer/Appropriate Adult/Personal Assistant

Person(s) Allegedly Causing Harm

Person who concerns are about

Name of Person(s) Allegedly Causing Harm:

First Name

Surname

Date of Birth:

Role:

Sex:

Address:

Post Code:

Telephone Number:

Email Address:

Actions already taken: Are you aware of any An Garda Siochana/ other statutory bodies involvement in this case? If yes, please provide details

Have any of the individual's family or carers been notified of this concern?

Yes

If yes please provide details of what was said/action agreed.

Is the Lead Safeguarding Officer aware of this referral?

Yes

Details of Concern

Date Occurred:

Time Occurred:

Name of Club:

Incident Type:

Category of Concern:

Inside or Outside of Sport:

Describe your concerns: Include all the relevant information, such as detailed description of your concerns and reasons for these. Please describe any injuries or actions causing concern and whether you are recording these as fact, opinion or hearsay.

Are you reporting your own concerns or responding to concerns raised by someone else?

If responding to concerns raised by someone else please their contact information. Name, Position within the sport or relationshop to the individual concerned, telephone number, email address

Witnesses or Supporting Accounts Please provide details of any one who has shared your concerns or witnessed any incident: Name, Position within the sport or relationship to the individual concerned, DOB, Address, Postcode, Telephone Number, Email Address

Conflicts of Interest: Do you have any relationship with anyone involved in this case which could cause a conflict of interest in any investigations? If yes, please describe your relationship

Lower Level Concern? If this is a lower level concern, please confirm that it has been reported and reviewed by Club, League, National Body prior to this report. If not, please state why

Signature:

The information you have provided on this form will be used for the purposes of recording and handling your concern. The FAI has a legitimate interest under the relevant legislation for processing this information. The information that you provide will be used and stored in accordance with the FAI’s privacy notice, available here.