Safeguarding Incident Report Form

If you have knowledge that a person’s safety might be in danger, please complete this form to the best of your knowledge.

You may wish to complete this form before contacting the Safeguarding Lead or you may wish to complete the report after contacting this person (depending on the level of risk).

If you wish to inform us of a Safeguarding Incident verbally before completing this form, please contact the Designated Safeguarding Lead/s (Stacey Swimer: International Programmes, Emily Cookson: UK Programmes). After becoming aware of an incident, you need to report it to a Designated Safeguarding Lead immediately, and you need to submit this form within 48 hours of the incident occurring.

This report is to be used as a tool to develop the most unbiased information-based report possible. For confidentiality reasons, the report should be written and submitted solely by you. Your submitted form will only be accessed by the Designated Safeguarding Leads. It will be held in a safe and secure place and treated in the strictest confidence.

What is your name?*

What is your job title?*

Who is your employer?*

What is your relationship to the adult, young person, or child at risk? *

What is their name? *

(if you are unsure of their name, please write "unsure")

What is their gender?*

WomanManNon-binaryUnsure

How old are they? *

(please enter their Date of Birth if you know it) (if you are unsure of their age, please write "unsure")

What is their address?*

(if you are unsure of their address, please write "unsure")

Please state any relevant guardian information or responsible partner organisations *

(if irrelevant, please write: N/A)

How did you become aware of this concern?*

the abuse, harassment or harm was observed or suspectedthe abuse, harrassment or harm was shared to you by someone elsethe abuse, harrassment or harm was shared to you by the person at risk

What was the date and time of the alleged incident?*

Where did this incident happen? *

(if you are unsure, please write "unsure")

What is the name of the alleged perpetrator? (if you are unsure, please write "unsure")*

(if you are unsure, please write "unsure")

Is the alleged perpetrator a staff member, volunteer, trustee or partner staff member?*

YesNoUnsure

What is the suspected, observed or disclosed nature of this incident? (please select all that apply)*

Other*

Please state:

Your personal observations (visible injuries, emotional state, etc.) [N.B. Make a clear distinction between what is fact and what is opinion or hearsay]

Exactly what the person or other source said to you [if relevant] and how you responded to him or her: [Do not lead the victim. Record actual details]

Please state any other relevant information not previously covered*

Were there any other children or young people involved in the alleged incident?*

YesNoUnsure

Safeguarding Incident Report Form

About You

About the adult, young person or child at risk

About your concern