Safeguarding Incident Report Form

[gravitypdf name=”PDF Print out of Safeguarding incident form” id=”5f95e6b93a00a” text=”Download PDF form”]

Your details
Name
First Last
Organisation*
Other organisation
Your role*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Enter Email Confirm Email
Child details
Child's Name
First Last
Child's Date of birth
Date Format: MM slash DD slash YYYY
Child's ethnicity
Does child have a disability?*
If yes, please provide details here
Parent/Carer's Name(s)
Are these the same as your details given at the top of this form?*
Parent's / Carer's Name*
First Last
Parent's / Carer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent's / Carer's Phone
Parent's / Carer's Email*
Enter Email Confirm Email
Details of incident
Have Parent's / Carer's been notified of this incident?*
If Yes, please provide details of what was said / agreed:
Are you reporting your own concerns or responding to concerns raised by someone else?*
- Response to my own concerns
- Responding to concerns raised by someone else
If responding to concerns raised by someone else, please provide further details below:
Time of incident

: HH

MM
Date of incident
Date Format: MM slash DD slash YYYY
Are you reporting this incident as;*
- Fact
- Opinion
- Hearsay
Details of incident or concerns
Please include other relevant information such as the description of any injuries.
Child's account of incident
Witness accounts
Were there any witnesses to this incident*
Please provide any witness accounts of the incident:
Witness name
First Last
Position within the organisation or relationship to the child:
Was this witness a child?
Date of birth (if child)
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Actions taken
Please provide details of action take to date
External agencies
Has the incident been reported to any external agencies?
If yes, please provide further details:
Name of organisation
Contact person
First Last
Phone
Email
Agreed actions or advice given:
Consent
Consent*
I understand this report may be disclosed to Social Services or the Police
This form will be sent to the Hayley's Swimming School Child Protection Officer (CPO) in line with our reporting procedures.

Andre Roberts
Designated safeguarding officer
Tel: 07480234807
Email: bookings@hayleysswimmingschool.co.uk
Your signature*
Print name
Date
Date Format: MM slash DD slash YYYY
CAPTCHA

Safeguarding Incident Report Form

Your details

Child details

Parent/Carer's Name(s)

Details of incident

Witness accounts

Actions taken

External agencies

Consent