Disclosure/Incident report
Private and Confidential
Name of individual affected
*
First Name
Last Name
Is this individual either of the following?
*
Under the age of 18
A vulnerable adult
None
Any additional individuals involved:
Details of disclosure or incident - a factual recount of what was said by the disclosing person or events that occured, including as much detail as possible (Do not include any personal opinions about the disclosure)
*
Please include any documents or photographs that may be relevant to your report
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Do you believe anyone involved is immediately at risk of harm?
*
Yes
No
Your Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
I confirm that this disclosure report is accurate and true to the best of my knowledge and I understand that details from this report may be shared with relevant authorities and with the City Church Swansea and Elim National safeguarding teams.
*
I agree
Date
*
-
Month
-
Day
Year
Date
Signature
*
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Should be Empty: