Youth Protection · Rotary District 3860

Incident/Allegation Report

For Club Presidents reporting a youth protection incident or allegation to the District Governor.

Confidential. Nothing you type leaves your device. The report is created in your browser and is never sent to or stored by this website. Nothing is saved if you close the page, so download the PDF before you leave.

This template is designed to ensure the Club President provides all critical information while maintaining the legal confidentiality required by RA 7610 and the Safe Spaces Act.

Prefer to write it by hand? Download the blank template.

Memo

TO:: District Governor, Rotary International District 3860
ATTN:: District Youth Protection Officer (DYPO), and your Assistant Governor
SUBJECT:: URGENT: Youth Protection Incident/Allegation Report

From: President, Rotary Club of*

Assistant Governor, Area

Date of report

1. General information

Date of incident/discovery*

Time

Location of incident

A club meeting, RYLA camp, online, or elsewhere.

Rotary program involved

e.g. Interact, Youth Exchange, RYLA, or Other.

2. Parties involved

Note: To protect the minor's privacy under RA 7610, use initials or a "Case ID" if transmitting via unencrypted email. Full names should only be shared via secure/verbal channels.

Alleged victim (initials or Case ID)

Age

Gender

Alleged perpetrator

Role

Witnesses (if any)

Names and contact details, one per line.

3. Description of the allegation

Description*

Provide a concise, factual summary of the incident or suspicion. Avoid personal opinions or conclusions.

4. Immediate actions taken

Tick each action already taken.

Youth Safety: Confirmed the youth is in a safe environment.

Medical Care: (If applicable) Youth was referred to

Police/DSWD Notification: Reported to

Suspension: The accused has been immediately suspended from all youth-facing Rotary activities.

5. Club contact person

Club Youth Protection Officer

Contact number/email

6. Declaration

I certify that this report is made in good faith and in compliance with the District 3860 Youth Protection Policy and the Rotary International Code of Policies.

President's name*

Rotary year

Signature

Sign here with your finger or mouse

Send the PDF to the District Governor, the District Youth Protection Officer and your Assistant Governor. If you send it by unencrypted email, make sure the victim is identified only by initials or a Case ID.