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Safeguarding incident form
CONFIDENTIAL
All information recorded on this form should be factual and not the feelings or thoughts of the person completing the form. Please complete as much of the following as possible.
If you would prefer to fill in a physical form, please download
Safeguarding Incident Form ->
and send it to: Safeguarding Officer:
[email protected]
or Deputy Safeguarding Officer:
[email protected]
Name of child/young person/adult
*
Age and date of birth
*
Gender
*
Parent’s/carer’s name(s) if under 18
*
Home address (and phone no. if available)
*
Siblings (if any)
*
Name of organisation/church
*
Your name
*
Your position and relationship to the child/young person/adult
*
Are you reporting your own concerns or passing on those of someone else? Give details
*
Brief description of what prompted the concerns: including dates, times etc. of any specific incidents, sequence of events, actual words used/observations. Keep factual
*
Any physical signs? Behavioural signs? Indirect signs?
*
Has the individual spoken to you? If so, what was said? Please report exactly what they said (using their language) and what you said: (remember; do not lead the individual - record actual details.) Continue on separate sheet if necessary
*
Have the parents spoken to you? If so, what was said?
*
Has anyone alleged to be/is suspected of being the abuser? Give any other details that you feel will be important
*
Have you consulted anyone else? Give any other details that you feel will be important
*
In what capacity have you had contact with the child/young person/adult?
*
To whom reported and date of reporting
*
Action taken
*
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