Serious Incident Report

Formal complaint must be completed in writing to the CBUMSC Risk Management Manger or the using this Serious Occurrence Report Form.

Your Role:

Circumstances surrounding the incident:

Name of the Accused:

Relationship with the Complainant

Time(s) of the incident:

Date(s):

Location(s) where the alleged incident(s) would have taken place:

Name of Witness (1)

Name of Witness (2)

Name of Witness (3)

STATEMENT - (please provide a detailed description of the inappropriate behavior or conduct:

Corner Brook United Soccer Club

P. O. Box 26 Corner Brook, NL A2H 3C6

To be decided

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