Incident & Disclosure Form
This form must be completed as soon as possible (and within 24 hours) after any incident raising child protection concerns, breaches of licensing arrangements or breaches of WAB codes of conducts. If the incident took place on set, a copy of this form should also be given to the production’s designated safeguarding officer (where there is one)
About the person
Please give as much information as possible about the person who has given you cause for concern
Name
First Name
Last Name
Age (if known)
Address (if known)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Any other relevant info:
A description
Does this incident/disclosure involve another person?
Yes
No
If yes, please write below:
If it is a participant, please let us know which cohort they are from:
000 - Rocks
001 - Dreamers
002 - Ish
003 - Chork
004 - Major Players
005 - Brides
BIFA Breakthrough Performers
Other/Not a participant (please specify)
About the incident/disclosure
Name of event/ session/ production the incident took place
Date of incident/disclosure
-
Day
-
Month
Year
Date Picker Icon
Time of incident/disclosure
Hour Minutes
AM
PM
AM/PM Option
Staff/team members present
Type of abuse witnessed/disclosed
Bullying
Harassment
Psychological abuse
Emotional abuse
Physical abuse
Sexual abuse
Financial abuse
Neglect
Discriminatory abuse
Organisational or Institutional abuse
Self-Neglect
Self-Harm
Concerns about Online safety
Not sure
What happened?
Include as much detail as you can about what you saw or heard. Ensure that it is factual and record the actual words used rather than your interpretation of what was said. If the disclosure is a historical event, please include the dates if known. Information should also include information about any adults involved, their role on the production and who they work for.
Does the incident/disclosure need to be reported to the police, MASH (Multi-Agency Safeguarding Hub) or Social Services?
Yes
No
About Yourself
Please fill out some details about yourself so we can contact you if further information is required. If you prefer to remain anonymous, please skip to the next section.
Name
First Name
Last Name
Role
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Actions already taken
Include whether or not you have spoken to the child’s parent/carer or anyone connected to the production and any actions they took in response.
Signature
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Submit
Should be Empty: