If an individual is at an immediate risk of harm please report to the police and/or Children’s Services or the Local Authority Designated Officer before informing Motorsport UK Safeguarding team via safeguarding@motorsportuk.org 
Date of Referral		Guide notes	

Date of incident	Incident 1. 	Incident 2.	If your concern relates to more than one incident or concern that have taken place over a period of time, please specify here.	
	Incident 3.	Incident 4.		

Previous concerns	Yes	No	Details - 	If you are aware of previous concerns raised about this individual please ad this here. 	

Referrer details

	Name	Please give details of your position within the club if applicable, such as Club Safeguarding Officer. 	
	Club		
	Role 		
	Contact number 		
Referral to external agencies		Please include details of any referral you have made to external agencies such as Police/ Local Authority Designated Officer. 	

Who is this report about?	Child’s welfare/safety 	Yes 	No 	Please highlight the relevant responses, giving as much information as you have available. 
 
If your concern relates to more than one person, please be specific about who they are and whether they have specific needs such as any disabilities, special educational needs or additional vulnerabilities. 

Complete multiple forms if required.	
	Adult’s welfare/safety 	Yes 	No 		
	Adults behaviour toward a child or vulnerable adult	Yes 	No 		
Child’s details 	Name 	D.O. B			
Motorsport ID number		Club /
Team			
Address			

Parent/carer details 

 	Name 		
	Is parent/carer aware of concern?	Yes / No		
	If yes have they consented to sharing information for safeguarding purposes?	Yes / No		
	Contact number			

Child’s family		Please give details of any further family members e.g. Mother, father, Carer/Guardian, siblings. 
	
Adult’s name		D.O. B		Please highlight the relevant responses, giving as much information as you have available.	
Are they aware of this referral	Yes 	No	If yes do they consented to sharing information for safeguarding purposes?	Yes 	No		
Motorsport ID number		Club / Team			

Address

Contact number			

Adult whose behaviour toward a child or vulnerable adult is of concern	
Adult’s name		D.O. B		Please insure you inform us of all relevant details. 

Please include their role (competitor/team, driver coach/Motorsport UK Official)	
Are they aware of this referral?	Yes 	No 		

If yes, please give details of all communication / actions taken regarding concern

Role in motorsport 			
Motorsport ID number		Club / Team			
Address

Contact number			

How do you know about the concerns you are reporting?	

	You might have;
 directly witnessed an incident of concern, someone may have informed you of it, a child may have disclosed to you that they are being abused. 

Please state who and in your own words describe how you have received this information.
If you have received a written report please ensure it is made available with this form. 	

Details of your concerns

	

	When a concern is raised, you should not embark upon an internal investigation. 

This means that in the initial stages, there is no need to gather statements or interview anyone. 
If possible please establish / include information to enable us to complete an initial assessment of your concern. 
If possible tell us the following information: 
•	What has happened 
•	Where it happened 
•	When it happened
•	Who is involved, and who did what 
•	Why did it happen 

Try to report in a chronological order. If your information has come to you from a number of individuals, please be clear about who said what.

Has the club taken any action to manage this incident?

		Who have you have spoken to about this matter; has it been reported to the Club Safeguarding Officer? Anything else you think might be relevant.	

Are you aware of any other evidence which is relevant to your concerns?		This might include photographs, video footage or screenshots. Or you may be aware that an injured person has seen a doctor or been to hospital to seek medical help. You can use this box to tell us about any other information which you think might be relevant.	
Please send this form password protected to safeguarding@motorsportuk.org.
If you wish to discuss your concern in before submitting it, please call the Motorsport UK Safeguarding Case Manager on:
T:  +44 (0) 1753 765071
M: +44 (0) 7519 801674
Please ensure that this form is kept secure and confidential at all times