Safeguarding Form

SAFEGUARDING REPORT FORM
When reporting safeguarding issues we always do so with the best intent. Once assessed any referal may be passed to a supporting authority to best safeguard an individual(s). We accept that as part of this process we may be required to provide statements and/or evidence to outside agencies and we support this readily.

Safety is paramount to all we do.
Is this issue related to*
Child/Young person or Vulnerable Adult
Please state your name*

First NameLast Name
Your mobile telephone number*
Your email address*
example@example.com
INFORMATION ABOUT PERSON BEING REFERRED
Their name*

First NameLast Name
Their date of birth

DayMonthYear
Date
Their Phone Number
Their address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INFORMATION ABOUT THE ISSUE BEING REPORTED
Actual date of issue*

DayMonthYear
Date
Time the issue take place (if known)
Where did the issue take place
Was anyone else present - if yes who*
Describe as best you can the nature of the issue you are reporting*
For example: Any physical, behavioural or other indicators e.g. bruises, behaviour changes, periods of absence. Any information relating to the young person's home life e.g. substance abuse, domestic violence, mental health issues.
What has happened so far, if anything*
Has any external agency been informed

PoliceSocial CareFamily/Carer/GuardianOther
If so please provide case/log numbers and dates informed
Any other information
Date reporting issue*

DayMonthYear
Date
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS FORM
Should be Empty:

SAFEGUARDING REPORT FORM

INFORMATION ABOUT PERSON BEING REFERRED

INFORMATION ABOUT THE ISSUE BEING REPORTED