Safeguarding Reporting Form

Safeguarding Reporting Form
This form should be used to record safeguarding concerns relating to Children and/or Vulnerable persons. In an emergency, please do not delay in informing the police or social services. All the information must be treated as confidential and reported to the Designated Safeguarding Officer within one working day or the next working day if it's a weekend.

The form should be completed at the time or immediately following disclosure, but after all necessary emergency actions have been taken. Please complete the form as fully as possible.
Your Details - the person completing the form:
Name*

First NameLast Name
Position*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Details of the person affected
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

Town/CityState / Province

Postcode
Email*
example@example.com
Phone Number*

Area CodePhone Number
Details of the incident (please describe in details using only the facts)*
Details of concern – please continue on additional sheets if required - Are you reporting your own concerns or passing on those of somebody else? (Give details) Brief description of what has prompted these concerns. Include dates, times, venues etc. of any specific incidents and descriptions of any alleged or suspected abuse (emotional, sexual, physical abuse, discrimination, or harassment), include descriptions of any injuries or marks which are observed. Include any relevant background that might explain the student’s behaviour.
Other present or potential witnesses
Names, Addresses, Telephone Numbers, Emails.
Additional relevant information (please detail anything else that you believe to be helpful or important)
For completion by the reporting person, with the Safeguarding Officer, Does the concern fall into one of the following categories?

	Tick Box
Neglect
Physical Abuse
Mental Health
Sexual Abuse
Emotional Abuse
Allegation against Staff
Bullying

Other:
Signed by Safeguarding Officer

Clear
Signed by Reporting Person

Clear
Has the information been passed to any other agencies? (Please give details) If not, please record reasons why.
Signed by Safeguarding Officer

Clear
Completed by:
Date and Time

DayMonthYear
The chart above is a useful and simple way of recording injuries as an aid to later diagnosis. It is better to record what is actually observed than to speculate on the cause of the injuries at this stage.

If the body chart is to serve as a monitoring tool for minor injuries observed over a period of weeks (or even months), a new body chart should be used on each occasion. It is therefore very important to be consistent in the method of recording injuries so that comparisons can be made with earlier charts. Where several different staff may be completing the monitoring forms, managers should ensure they understand what is required of them.

The following points should be covered:
- Describe any marks, swelling, lacerations or other injuries carefully (cuts, bruises scratches)
- Describe the colour (brown/yellow/blue), size and shape of any bruises and indicate their location on the body chart; also describe any pattern if there are several bruises close together
- Briefly list any relevant circumstances witnessed, such as anger or aggression by vulnerable adult or by anyone in contact with the vulnerable adult
- Also record any explanations of injuries given immediately by the vulnerable adult and any other witnesses
- Ensure that for each chart completed the date and time of examination are clearly entered along with the name of the person completing the chart.
Should be Empty:

Safeguarding Reporting Form

Your Details - the person completing the form:

Details of the person affected

Other present or potential witnesses

For completion by the reporting person, with the Safeguarding Officer, Does the concern fall into one of the following categories?