Primary Organisation Name? (e.g. Club name) Please spell out in full, avoid acronyms e.g. FC for Football Club
League
Name of who received the call for help?
Full Name of Person requesting assistance?
*
First Name
*
Lastname
*
Email (preferred)
*
Phone (Mobile)
Represents the Organisation in what capacity? (e.g. President, Secretary, etc)
*
Club say they are a ClubCare Member?
*
Select an option
Yes
No
Type of Incident?
*
Select an option
INCIDENT Suicide
INCIDENT Suicide (repeat)
INCIDENT Death General (sudden)
INCIDENT Death Car Crash (sudden)
INCIDENT Death Sickness (long term)
INCIDENT Death On-field
INCIDENT Death Off-field (game related)
INCIDENT Injury On-field
INCIDENT Injury Off-field
INCIDENT Criminality (other than death)
COMMUNITY ISSUE – Sickness
COMMUNITY ISSUE – Drugs
COMMUNITY ISSUE – Division
COMMUNITY ISSUE – Conflict
COMMUNITY ISSUE – Game Loss
COMMUNITY ISSUE – Unethical Behaviour
COMMUNITY ISSUE – Mental Health
COMMUNITY ISSUE – Other
Group provided with assistance?
*
Select an option
League/Association Offices
Club/Community
Club Family
Wider Community
Date of Incident
Summerise Incident or Issue (Title)
Detailed Description of Incident or Issue
Additional Info or Response (with Dates) so far?
Next action
Select an option
Club Debrief
Follow up and Review
No Further Action Required
Next Action Due by
CCA Regional Coordinator Assigned
CCA Manager Assigned
Primary Chaplain Assigned
Primary Chaplain Responsibility
Chaplain 2 Assigned
Chaplain 2 Responsibility
Chaplain 3 Assigned
Chaplain 3 Responsibility