Urban Light - Safeguarding/Incident Report Form (SGP4-EN)
This Safeguarding Concern Report Form has three parts:
  • Part 1: About you (*)
  • Part 2: About the Cause for Concern
  • Part 3: About the reason for the concern
(*)For your protection and privacy parts of this report are optional
  • You can skip parts of the report form. To protect your anonymity
  • If you do choose to provide your name and contact details, we will keep this information confidential.
  • It may be helpful for us to be able to contact you. To follow up and keep you informed of developments regarding this report, and to ask you about additional information that may be useful for the Foundation in dealing with this matter (in accordance with our Safeguarding Policy)
  • You can also skip some sections if you don't have enough information. If you have some concerns, that you are not sure about, please let us know your suspicions
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Section 1: About you
By filling in your name and contact details below, you consent to Urban Light Foundation contacting you, to follow up, request further information, and inform you of the progress made regarding this report

Your name:

Please provide your full name and nickname as appropriate

Your position/relationship to Urban Light:

For example, Staff member, UL Client, Guest/Visitor, Volunteer, Intern, Board Member, Supporter, Partner Organization, or Other

Your Contact details:

How would you like us to contact you to keep you updated? Phone, Email, social media, In Person, through a trusted guardian or contact person. Please provide the exact details below

Is your report related to any of the following?

(Please check all that apply)

 *
Required
Section 2: About the Concern
Please provide as much information as you can, to help us identify the person/people who people who you are concerned about.

Who are you concerned about?

Please provide full names, as well as nicknames if possible.

How do you know them?

Do you suspect that they are AT HIGH RISK of experiencing any of the following forms of abuse?

(Please check all that apply)

 *
Required

Do you suspect that they are  IN IMMEDIATE DANGER/ALREADY EXPERIENCING  of experiencing any of the following forms of abuse?

(Please check all that apply)

 *
Required
Please provide more information about the issues, suspected issues, or potential issues that you are concerned about:
 *

Please provide as much information as you can, to help us identify the person/people who people who you are concerned about.

Useful information can include: Gender, Age or Birthdates (estimates of age are fine if you’re not sure), Nationality, Ethnicity, Legal Status (issues with statelessness)

What is their current living situation?

Where are they now? Are they in a place of safety? Do they live with others? Do they have trusted adults living with them? If they do not have a stable home, where do they spend most of their time? Please provide an exact address if possible.

Are there any immediate safety issues that you have not yet mentioned?

For example, urgent medical needs, difficulties with transportation, difficulty in contacting the person/people that you are concerned about, or something potentially dangerous to them.

Is there any other important information we should know about them?

Disabilities, learning impairments, language barriers, cultural issues, power dynamics, or anything else you think might be significant information, that could help Urban Light to assist this person.

How can we find them or contact them?

Can we contact them directly? Can we contact someone close to them? Please provide their contact details or the contact details of a trusted adult, if possible. 

Urban Light Foundation will keep their information private, and will not inform them of your involvement in this report.

Section 2: About the Cause for Concern
Please provide some information on how you came to know about this issue

When did you first become suspicious or concerned?

How did you first find out about the issue/concern? 

Is this primarily your concern? or did someone else tell you about it? If so, who told you?

Is the issue/concern something that has been observed, or is it suspected?

Who observed or suspects the issue/concern?

If this person was not you, can we contact them? Please provide contact details if you can. 

If you provide anyone’s name and contact details, Urban Light Foundation will keep their information private, and will not inform them of your involvement in this report.

Causes for Concern: Suspected Perpetrators
Please answer the remaining questions if you believe that there is a person (or people) who are directly or indirectly causing harm or abusing the person you are concerned about. 

Urban Light Foundation will protect your privacy, and will not inform the suspected perpetrator of your involvement in this report.

Who are the suspected perpetrators? 

For example, Staff or representative(s) of Urban Light, an Urban Light client, someone in the person’s close friendship circle, someone in the person’s family, someone in the community, someone online, or someone unknown

Name and details of the suspected perpetrator(s)

Please provide as much information as you can, to help us identify the person/people suspected of causing the harm or abuse:

How can we find or contact the suspected perpetrator?

Can we contact them directly? Can we contact someone close to them?

Please provide contact details if you can. 

Urban Light Foundation will protect your privacy, and will not inform the suspected perpetrator of your involvement in this report.

Is there any other important information we should know about the suspected perpetrator(s)?

For example, prior criminal record, abuse of power, and any other concerns you may have about them?

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