22001177
CCH HIILLD DA ABBU US SEE // M MO OLLEES ST TA AT TIIO ON N RREEPPO ORRT T FFO ORRM M
““CCO ON NFFIID DEEN NT TIIA ALL””
Name (s) of Children / Individual(s) of concern : _____________________________ Date of Occurrence : ____________________________________ Time of Occurrence : ____________________________________ Type of Concern : o o o o
Inappropriate behavior with a child Policy violation with a child Possible Risk of abuse Other concern : ___________________________________________ ___________________________________________
Described the Situation in detail - what happened, where (location) it happened, when it happened, who was involved (any witnesses), who was present and who was notified (and when) ?? Attach additional sheets if necessary and mark “Confidential” ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Submitted by {please print} : _____________________________________ Address : ____________________________________________________ Email : ___________________________ Telephone Number : _________________ Signature : ____________________________________
Date : ______________
SEND IMMEDIATELY TO BETH – WOOD PRESIDENT Dwight C. Rowland (
[email protected])
Report Form, cont.
Page – 2 -
Date received by Beth – Wood Baseball President : _______________________ Name : ___________________________________________ Address : _________________________________________ Telephone : ________________________________________ Was Police / State Authorities notified : Yes _____ No _____ If so when : ____________________________________ What was their recommendation / action about this investigation : _____________________________________________________ _____________________________________________________ Has this Situation occurred in the past (if so, when) ?? Attach additional sheets if necessary and mark “Confidential” _____________________________________________________ _____________________________________________________ What action was taken ?? How was the Situation handled, who was involved and who was questioned ?? Attach additional sheets if necessary and mark “Confidential” ______________________________________________________ ______________________________________________________ ______________________________________________________
Report Form, cont.
Page – 3 -
What is the follow – up plan ?? Does anyone need to be notified ?? Will this Situation need monitoring ?? _______________________________________________________ _______________________________________________________ Any additional comments / concerns : _______________________________________________________ _______________________________________________________
Signature of League President : __________________________________
Date : _______________________________
