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Safeguarding Disclosure Form
To report any safeguarding disclosures and concerns.
Responses will be seen by Amy Redman
“If for any reason you don’t want any of these people to see the response, please email your concern directly to the Diocesan Safeguarding Advisor (
safeguarding@blackburn.anglican.org
)
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Please check the correct box
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Church Staff
Volunteer
Church Member
Non Member
Required
Full Name of person completing Disclosure form:
*
Your answer
Please leave an email address or phone number.
*
Your answer
Date of Incident/Concern:
*
MM
/
DD
/
YYYY
Name/s of Person (First and Surname) this concern is about
*
Your answer
Details of Disclosure or Concern (Who, What, Where, When):
*
Your answer
Other Relevant Information:
Your answer
For staff use: LEAVE THIS SECTION BLANK (Action Taken)
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