Safeguarding Report Form

Please complete this form within 24 Hours of the incident happening/concern arising.

If the person at risk is in imminent danger of harm you should refer directly to the police or social services without delay.

Your name *

Email address *

Section 1a

Your Details

Role? *

Staff/Volunteer etc

Section 1b: Person at Risk’s Details (Please complete to the best of your Knowledge)

Child/Young Person or Adult? *

First & Last Name *

Known as

(If uses a different name)

Address inc. Postcode

Phone Number

Date of Birth

Gender *

Language spoken? *

Section 1c: Parent/Guardian/Essential Aid Details

Parent/Guardian/Essential Aid Name

Contact Information

Have parents /guardian/essential aid been notified of this incident/concern? *

If YES please provide details of what was said/action agreed:

If NO, please provide details of why:

Does the person have a perceived disability or accessibility needs? *

If yes, please give details.

Section 2: Details of Incident/Concern

Incident or Concern? *

Who does the Concern/Incident Involve? *

DETAILS OF THE INCIDENT OR CONCERNS *

What are you worried about? Who are you worried about? Where did the incident happen/concern arise? When (date and time of incident)? Any witnesses? Provide details of any other people involved in this incident or alleged to have caused the incident / injury.

Individual’s account of the Incident:

If recording a verbal disclosure by a person use their words.

Have You Reported The Incident To An External Agency? *

If YES please provide details what agency and what was said/action agreed:

Today's date *

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.