Form completed by
Date
Job title/ Role
Information about the person you have a safeguarding concern for:
Full Name
DOB/age
Gender
Additional needs:
(e.g. health/ disability/
social/ housing/other)
Current Address:
Email: Telephone Number:
G.P. Details if known:
If concern raised by a third party add their details here
Significant others if known (relatives, carers, friends, health/ social care/ other professionals)
Name
Relationship to person
Address
Details of Concern
Date of Incident:
What happened/ what is the concern?
Has the person involved expressed what they want to happen? Do they have mental capacity to make an informed decision?
Breach of Confidentiality – Information Sharing: Y/ N
Is the person concerned aware that the information has been shared with outside agencies and why?
Did the person give permission for the information to be shared with outside agencies?
What needs to happen? Note actions, including names of anyone whom your information was passed to and when
Status
Children: Is there a child or children or vulnerable adult in the household even if not the subject of the immediate safeguarding concern: Y/N
Details:
Date
Inform
Safeguarding Lead: Lynsey Heeley
Board of Trustees Aware
Record Keeping
Recorded securely on CRM System
Safeguarding incident record