Safeguarding Incident Report Form

    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.

    All information will be kept confidential. Unless urgent actions are needed to be taken

    Your Details – The person completing this form

    Name

    Position

    Telephone

    Email address

    Details of the person affected (If different from above)

    Name

    Position

    Telephone

    Email address

    Details of the incident (Please describe in detail using only the facts, write in sequence of events)

    Date and time of the incident

    Location of the incident

    Other present or potential witnesses

    Name

    Position

    Telephone

    Email address


    Name

    Position

    Telephone

    Email address

    Additional relevant information (please detail anything else that you believe to be helpful or important)

    I have completed this form and provided information that is factual and does not contain my own views or opinions on the matter.

    Name (Printed)

    Date

    Signature