Reporting Maltreatment, Violence, and Discrimination Incidents

Role/Position (if applicable):

Referring Organization/Institution (if any):

Full Name (if known):

Role/Position (e.g., other assisted person, colleague, superior, teacher, etc.):

Affiliated Organization/Institution (if different from yours):

Any Witnesses (Full Name, Role/Position if known):

Date of the Incidento:

Approximate Time:

Location (or context) of the Incident:

Detailed Description of the Incident:

Please provide a description of the observed or experienced events as precisely as possible. Include, if possible, the sequence of events, any words or gestures directed, any immediate consequences, reactions of those present, etc.

Physical Maltreatment:
Yes
No
Not Certain

Psychological or Verbal Violence:
Yes
No
Not Certain

Sexual Violence:
Yes
No
Not Certain

Discrimination (please specify if racial, gender, religious, etc.):
Yes
No
Not Certain

Bullying or Cyberbullying:
Yes
No
Not Certain

Other (please specify)

Has anyone already intervened? (e.g., a teacher, a superior, a colleague, law enforcement, healthcare professionals...)

Have any immediate protective measures been taken? (e.g., removal, suspension...)

Has a report or complaint been filed with other authorities? (please specify the authorities or offices involved)

Any previous similar incidents:

Any particular vulnerabilities (minors, disabilities, etc.):

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Reporting Maltreatment, Violence, and Discrimination Incidents

Sporteventi ASD Safeguarding Office Reporting Form

Reporter's Details

Details of the Person(s) Involved in the Incident

Description of the Incident

Type of Report

Actions or Interventions Already Taken

Other Relevant Information

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