Online Safeguarding Disclosure

Safeguarding Disclosure
Reference
Thank you for helping to keep people safe by completing this disclosure form. Disclosure is the process by which people start to share their experiences of abuse with others. This can take the form of physical, emotional or sexual abuse or neglect, or any combination of these. Please try to be as descriptive yet as objective as possible.
Who is giving this disclosure?*

Child/Young personParent/CarerTeam memberChurch memberDifferent Organisation
When a disclosure is made, it is important that the following procedure is followed:
- Remain calm - the person has decided to disclose to a trusted individual;
- Use TED (Tell, Explain, Describe) to ask only open questions such as:
  - 'Tell me what happened'
  - 'Please explain what you mean when you say .....'
  - 'Can you describe the person?' or 'Can you describe the place?'
Under no circumstances should a member of staff or volunteer carry out their own investigation into a disclosure, allegation or suspcion of abuse.
Details of the person affected
Name:*

First NameLast Name
Date of birth:

DayMonthYear
Date
If date of birth is not known*

0-17 years old18 and over
Regular attender of Citygate Church?*

YesNoNot sure
Details of incident
Summary of incident/concern:*
Provide a brief statement
Date and time of incident/concern:*

DayMonthYear
Date
Hour Minutes
Location of incident/concern:*
Please be as specific as possible.
Details of incident/concern:*
Write a detailed account of the incident/concern - include frequency of incident, facts and factual account of what happened. Where possible, use the language used by the affected person IN CAPITAL LETTERS to allow for easier differentiation.
Details of action person completing this incident/concern form has already taken:*
Your details - the person completing the form
Name:*

First NameLast Name
Role of person reporting incident/concern:*
Email of person reporting incident/concern:*
example@example.com
Body Map - Body

This form is to be completed at the same time (and attached to/stored with) the completed Incident of Concern form or Injury within the provision form for the same incident/injury.
Annotate Image
Thank you for filling in the form.

A member of the Safeguarding team will respond to you within 3 working days.
Should be Empty:

Safeguarding Disclosure

Details of the person affected

Details of incident

Your details - the person completing the form

Body Map - Body