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
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.
Additional relevant information (please detail anything else that you believe to be helpful or important)
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:
Has the information been passed to any other agencies? (Please give details) If not, please record reasons why.
Completed by:
Date and Time

DayMonthYear
Your information is confidential and securely stored. We only use it for processing and is kept secure, only essential parties will see this information such as our Designated Safeguarding Officers. We do not share your data unless legally required.
Should be Empty:

Safeguarding Reporting Form

Your Details - the person completing the form:

Details of the person affected

Does the concern fall into one of the following categories?