Safeguarding Concern Form

Please complete this form with the information available within 24 hours of becoming aware of a safeguarding incident or concern. You do not have to fill in all sections.

Please ensure you are as accurate and detailed as possible. Use quotes wherever possible, and do not interpret what was said using your own words.

Record what you said as well as what the child, young person or adult said.

Include details such as tone of voice, facial expression and body language.

If you have formed an opinion please state it, making it clear that it is your opinion and give reasons for forming that opinion.

The completed form must be submitted in order to notify the designated safeguarding person.

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Email *
Person at Risk - Name and D.O.B *
Person at Risk - Address (if known)
Person at Risk - Contact details (Phone/email)
Person Causing Concern - Name
Person Causing Concern - Contact details (phone/email)
Your name and role *
Your contact details (phone/email)
Date concern raised
MM
/
DD
/
YYYY

Nature of concern: (The Allegation / Behaviour / Risk that is causing concern):   

(Names of principle parties are essential. Please make a factual written record of your observations and any conversations) *
Please complete and submit: *
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