Safeguarding Concern Form
What date was the concern identified?
-
Day
-
Month
Year
Date
What time was the concern identified?
Hour Minutes
AM
PM
AM/PM Option
Name of COVEY staff member completing this form:
First Name
Last Name
Name of Participant:
First Name
Last Name
Name of Participant 2 (if applicable)
First Name
Last Name
Which project is the participant support in?
Which of these does this concern relate to? (select all that apply)
Child Protection
Adult Protection
Who did you report this concern to at COVEY?
First Name
Last Name
Please detail your safeguarding concern below:
Has this concern been reported to Social Work?
Yes
No
If not, please provide details on this:
Full name of person this was reported to at Social Work:
First Name
Last Name
What time was this reported to Social Work?
Hour Minutes
AM
PM
AM/PM Option
What action has been taken and who was this agreed by?
Save
Submit
Should be Empty: