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WELCOME TO DIAMOND CREEK BASEBALL CLUB

THE OFFICIAL HOME OF BASEBALL IN THE NILLUMBIK SHIRE

established 1995

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Diamond Creek Baseball Club Incident Report Form

Team*

Location*

Date and time*

Day

Month

Year

Time

:HoursMinutes

Person Reporting Incident

Full Name*

Role*

Email Address*

Details Of The Person Involved in The Incident

Full Name*

Age/Date of Birth (if under 18): *

Role*

Type of Incident (please tick the relevant box)

Multi choice*

Physical Injury

Emotional Distress

Child Abuse

Neglect

Other

Other Reason

Description of The Incident

Location Of Incident*

What Happened? (Provide a clear and detailed description of the incident):*

Witnesses (if any):

Name

Contact

Name

Contact

Action Taken

Immediate Response (e.g., first aid, reassurance):

Action Taken Immediate Response (e.g., first aid, reassurance):*

Was Emergency Medical Assistance Required?*

Yes

No

If Yes, Details of Emergency Services Contacted:

Parent/Guardian Notified?*

Yes

No

Time and Date of Notification

Day

Month

Year

Time

:HoursMinutes

Name of Person Notified:

Follow-Up Actions (e.g., check-in, counselling):

Safety/Wellbeing Officer Follow-Up

Date of Follow-Up:

Day

Month

Year

Person Contacted (e.g., player, parent):

Feedback Received:

Further Actions Taken (if any):

Multi choice

Counselling Recommended

Medical Follow-Up Recommended

Incident Closed

Referred to Committee for Review

Details:

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