SAFEGUARDING INCIDENT REPORT FORM

Brazilian Jiu-Jitsu Academy

CONFIDENTIAL DOCUMENT

You may submit this form anonymously. Providing contact details allows the academy to follow up but is not required. All reports will be treated seriously and logged securely.

SECTION 1: Reporter Information (Optional)

Name (optional)

Leave blank for anonymous submission

Email (optional - for acknowledgment only)

Phone (optional)

I am a:

Privacy: Providing contact details allows the academy to follow up but is not required. Anonymous reports are treated as valid.

SECTION 2: Incident Details

Date(s) of incident:

Time(s) of incident:

Location (mat, locker room, competition, travel, online, etc.):

Type of incident (check all that apply):

SECTION 3: Description (Most Important)

Please describe what happened in your own words:

Include: What occurred? Who was involved? Were there witnesses? Was force, coercion, pressure, or authority involved?

SECTION 4: Person(s) Involved

SECTION 5: Immediate Safety

Do you currently feel unsafe at the academy?

Yes No Unsure

Do you need immediate protection or accommodations?

Schedule separation Training partner change Temporary suspension of accused Other:

SECTION 6: Previous Reporting

Have you reported this before?

No Yes – internally Yes – to another academy Yes – to law enforcement

If yes, please explain briefly:

SECTION 7: Evidence (Optional)

Do you have any of the following? (check all that apply)

Note: Evidence can be provided later if requested. Do not feel you need to provide it now.

SECTION 8: Consent & Acknowledgment

I understand this report will be reviewed under the academy's safeguarding policy. I understand that serious allegations may be escalated to authorities to protect safety.

Signature (optional - type your name or leave blank for anonymous)

Date:

Submission ID

SG-1770151972952-6086

⚠️ Save or print this completed form for your records before submitting to your academy's safeguarding lead.

For Academy Use Only:

Received by: _________________ Date: _________ Time: _________

Safeguarding Lead Signature: _________________________________

About the Author

Dr. Sharlene Holt is an evidence-based programme designer and researcher specializing in safeguarding, trauma-informed practice, and neurodiversity-affirming approaches. Her work has reached over 16,000 children and young people through programmes like Boost (Gloucestershire Constabulary) and has been recognized with the Charlie Sallis Impact Award for Safeguarding Children and Young People (2024).