Safeguarding Expression of Concern Form
Concerns:
*
Name of Child/Adult:
*
First Name
Last Name
Date of Birth of Child Adult:
-
Month
-
Day
Year
Date
Person Reporting the Concern
Full Name:
First Name
Last Name
Remain Anonymous
Role (in relation to the child/adult:
*
Details of person reporting concerns:
*
Do these concerns relate to a specific incident/disclosure? If YES complete Section A & B; If NO, do NOT fill in section A and move straight to Section B
*
Yes
No
Date of incident/disclosure:
*
-
Month
-
Day
Year
Date
Time of incident/disclosure:
Hour Minutes
AM
PM
AM/PM Option
Location of incident/disclosure:
*
Date this form was completed:
*
-
Month
-
Day
Year
Date
Other persons present:
Section A
Details of concern/disclosure/incident:
(What was said, observed, reported in childs/adults own words)
Action taken:
(What did you do following the incident/disclosure/concern?)
Any other relevant information:
Section B
Date
*
-
Month
-
Day
Year
Date
Appendix One Checklist:
Concern described in sufficient detail?
Distinguished between fact, opinion and hearsay?
Individual’s own words used? (Swear words, insults or intimate vocabulary should be written down verbatim)
Jargon free?
Free from discrimination/stereotyping or assumptions?
Concern recorded and passed to DSL in a timely manner?
Appendix Two Feedback Slip
Safeguarding Concern Feedback Slip Ref Number. Date......................... Dear.........................Thank you for bringing to my attention your concern. We have followed our Safeguarding Procedure. Please see below the outcome.• Further Action Needed (The Designated Safeguarding Lead will speak to you directly regarding next steps) • No Further Action NeededPlease remember if you are not satisfied with how your concern has been dealt with, you have the right and duty to cascade your concern further. Please refer to our Safeguarding Policy. Safeguarding and Child Protection is EVERYONES responsibility.
Submit
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