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.
I confirm that this disclourse report is accurate and true to the best of my knowledge and that details from this disclosure will only be shared with relevant authorities and City Church Swansea and Elim safeguarding teams
*
I agree
Date
*
-
Month
-
Day
Year
Date
Signature
*
Continue
Continue
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