CISV Incident Report Form

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MEA House, Ellison Place Charity Registration: 1073308 Fax: +[44 191] 261 4710
Newcastle upon Tyne, NE1 8XS E-mail: International@cisv.org
England www.cisv.org

CISV Incident Report Form

This form is to be used when an incident occurs at a CISV international programme. Not every incident will require full
reporting. Examples of situations to report are those requiring medical (including psychological) attention, those involving
criminal behaviour as well as violations of CISV guidelines on Behaviour and Cultural Sensitivity where consequences have
been imposed. Although generally, it will be up to a Programme Director or Leader to do so, an Incident Report Form can be
filled in and submitted by anyone who feels there is a matter that should be reported. It should be sent in confidence to the
host National/Chapter Risk Manager, with a copy to incident.report.form@cisv.org (which will go to the International Risk
Manager and the Administrative Coordinators at the International Office). All related documentation should be attached.

The International Office will forward this report to relevant National Associations upon request.

For the confidential attention of Cisv Salvador Chapter

(Chapter/National Risk Manager, with a copy to
the International Risk Manager)
Host National Association Brazil
Programme and reference number V.2016.008
Programme Director Felipe Heizer
Date of incident 02.01.2017

CONTACT DETAILS OF PERSON SUBMITTING THIS FORM:

Position in the CISV Programme Delegation Leader
Given Name Tiago
Surname Perazzo Heeger
Number & Street Rua das Angélicas, 202 – Pituba
Town / City Salvador
Area / State / Province Bahia
Country Brazil Postcode / Zip code 41.810-060
Country Code Area Code Local Number
Tel +55 71 33596297
Fax
Mobile Number +55 71 987118010
E mail

INCIDENT DETAILS
A. People Involved
Names of CISV People Involved Their NA / Their Role (participant, Name of Parent /
PA Chapter leader, staff etc) Guardian if a child
Tiago Perazzo Brazil Salvador Leader
Eleonora Loi Brazil Salvador Participant Barbara
Pedro Machado Brazil Salvador Participant Mariana

Names of non-CISV People Involved

If a child was involved, was the Parent/Guardian contacted at the time? (Yes or no, plus any relevant details)
No, it was unnecessary.

Who in CISV was contacted at the time? (Chapter/National Risk Manager, Host/Sending NA, International Committee, IO)
None

CISV International Ltd (Valid from 2011) Page 1 of 2

Official Form
B. Description of Situation
Was this incident (please Medical Training Behaviour X Criminal Other
tick applicable boxes)

Please describe the incident in detail using additional sheets if necessary (please put your name and programme
reference number on any attached sheets):
The situation occurred during kids was supposed to be passing sun screen and bug repellent, and the leader was asking
the participant to do it, but the kids was refusing in the beginning. Happen that I (leader) was stressed because didn’t got
any sleep, and coment to Pedro that Eleonora was been refusing to pass the bug repellent and I got stressed and said
that Eleonora was stupid. At the time I didn’t occurred to me that I was had this bad behaviour, and after Pedro told
Eleonora. When they had the delegation time, we talked about it and I apologize to her and say that at the moment I was
stressed and won’t happen again, but we also talk about that bug repellent and sun screen was a camp rule, since we
were having a lot of activities outside and happen to the campsite has lots of mosquito.

When there is a need to indicate where on the body a person received an injury, please complete and attach an Incident
Report Form Appendix - Body Chart. The body chart must be completed by hand; it can then be scanned and emailed.

Action taken at the time and any follow-up:

I apologize to her at the moment we talked about, and tomorrow I will apologize to her again and explain about the
situation. Also it got agreed that I was trying to get enough sleep for don’t pass for this kind of situations again.

If this was a medical incident:

Where was it treated?
Name of attending physician
Medicine prescribed
Follow-up treatment, if any
Please attach any official medical reports, health forms available

Was this a situation where Police or other Authorities were involved? (yes or no and relevant details)

If yes, is there an official Police or civil report available? (If yes, please attach it or explain why not)

Was the media present? If so, which ones and who from CISV spoke with them?

Signature of person submitting (Day / Month / Year)

this form (electronic signature is
accepted) Tiago Perazzo Heeger 02.01.2016

CISV International Ltd (Valid from 2011) Page 2 of 2

Official Form