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Safeguarding, Welfare and Wellbeing Concern Form

This form is for apprentices who want to tell us about a safeguarding concern, welfare concern, wellbeing concern, something that has happened to you or someone else, or something that is worrying you.

You do not need to wait until something serious has happened to use this form. If something feels wrong, upsetting, unsafe, or worrying, please tell us.

Your concern will be taken seriously and passed to the appropriate safeguarding lead. We may need to share information with other people or agencies where necessary in order to help keep you or others safe.

Section 1: About you

1. Full Name

2. Date of birth

3. Apprenticeship Cohort

4. Best number to contact you on

5. Your email address

Section 2: What is this about?

6. What best describes your concern?

I am worried about myself

I am worried about another apprentice

I am worried about someone outside of HSA

Something has happened to me

Something has happened to someone else

I need support or advice

I want to report bullying, harassment, discrimination, or inappropriate behaviour

I am worried about my safety

I am worried about someone’s mental health or wellbeing

I am worried about neglect or abuse

Other

7. What type of concern is this? Select all that apply.

Please tell us what you are worried about (Include as much or as little detail as you feel able to share.)

8. Are you safe at the moment?

Yes

Not sure

9. Would you like someone from HSA to contact you as soon as possible?

Yes