Safeguarding Report Form

This form is for staff, contractors or volunteers at City Life Church (or one of their projects) who don't have access to My Concern but need to report a safeguarding concern or incident, such as a disclosure, relating to someone they are working with or supporting.

In all cases (unless it is regarding him), please call Paul Woodman (DSL) on 07387 108669 - or Naomi Sebborn (Trustee responsible for Safeguarding) on 07812 054059. If Naomi is implicated, call ThirtyOne:Eight on 0303 003 1111.

If neither are available, email City Life Church (care@citylife.org.uk), call ThirtyOne:Eight (0303 003 1111) or if it involves a child, call Southampton City Council Children Resource Service (formerly MASH) on 02380 833004.

Once submitted the form will be sent to Paul (or Naomi), who will contact the relevant manager(s) and partner organisations where required (e.g. HIA or SCC). If further information is required, they will contact you on the email/number provided.

Does the incident/concern relate to Paul Woodman?*

YesNo

Name*

First NameLast Name

Email*

example@example.com

Contact Number*

Please enter a valid phone number.

Which part of City Life Church are you involved with? (Please select the option that most relates to the incident/concern being reported)*

Who has been, or is being, affected?*

This MUST include the person(s) name, date of birth and details of anyone else involved.

What has happened... or you are concerned is happening?*

What action have you taken?*

When did the incident (or what is concerning you) occur?*

Where did the incident (or what is concerning you) occur?*

Further Comments

Has explicit consent been obtained from the adult at risk (or child's parent/carer) for referral?*

YesNo

What is the reason, under the Data Protection Act 1998, for making the referral without consent?

Sharing is in the vital interests of the person or another personSharing of information for crime purposesSharing is in the substantial public interestOther

Safeguarding Report Form

About You

About the incident or concern

Consent