Incident Report Form
To be Completed: ASAP
Staff Name (Tutor):
*
Tutor Name
Staff Name (Assistant):
*
Assistant Name
Witness:
Young Person:
*
Initials ONLY!
Local Authority
Please Select
Calderdale
Doncaster
Kirklees
Wakefield
Date of Incident:
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date of Report:
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Location:
*
Time:
*
Hour Minutes
AM
PM
AM/PM Option
Police REF Number / Relevant Contact Person:
If in the reporting of this incident you were provided a reference number by the Police or any other service, please enter it here.
What Happened:
Describe in your own words. If safeguarding in the words of the young person; remember no leading questions. Try to include times, positions of people, equipment, weather conditions etc.
How Did The Incident End:
For example, hospital visit, police intervention etc. Log as many professional details as possible here.
Further Help Required? (Staff)
Please Select
Yes
No
Not Applicable
Do you need any further help such as counselling as a staff member?
Further Help Required? (Young Person)
Please Select
Yes
No
Not Applicable
Does the young person require further assistance?
Incident Discussion?
Please Select
Yes
No
Not Applicable
Does the incident need further discussion at a team meeting?
Additional Notes:
In additional information.
Additional Documentation:
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