Report of Concern

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Report of Concern

This 'Report of Concern' form exists to raise any concerns you may have of harm having occurred, or occurring in the future.

CALL 999 or 101 NOW IF the person for whom you are concerned is at immediate risk of serious harm.

If you wish to discuss your concern with an external agency before reporting it locally you can call thirtyone:eight on 0303 003 1111.

Our Safeguarding Coordinators, Catherine Dalton and Iain Morrison, will receive a notification when you submit this form.

Category of concern *

A disclosure of abuse, neglect or, risk of harm to yourself

A disclosure from a victim of abuse, neglect, or risk of harm

Your own observations and/or suspicion of abuse, neglect, or risk of harm

A suspicion of abuse, neglect, or risk of harm passed to you

A general concern

Other:

Concern for *

a child (anyone under 18)

an adult at risk (over 18 and are unable to safeguard their own well-being, property, rights or other interests, are at risk of harm, and because they are affected by disability, mental disorder, illness or physical or mental infirmity, are more vulnerable to being harmed than adults who are not so affected.)

an adult

Category of harm to child *

Physical abuse - is the causing of physical harm to a child

Emotional abuse - is persistent emotional neglect or ill treatment of a child causing severe and persistent adverse effects on the child’s emotional development

Sexual abuse - is any act that involves the child in any activity for the sexual gratification of another whether or not it is claimed that the child either consented or assented.

Neglect

Bullying

N/A

Other:

Category of harm to adult *

Physical harm, including assault or restraint

Psychological harm, such as threats or verbal abuse/bullying

Sexual harm, being any sexual activity that the person does not understand or want (including verbal suggestive or sexual abuse or intimidation)

Neglect, such as deprivation of sufficient food or heating and failure to ensure appropriate care or treatment, including medical treatment

Financial harm, such as theft and fraud

N/A

Other:

Date and time of incident that provoked your concern

Date and time (or near enough) of the incident that you observed or had described to you

YYYY

Time

Location of incident *

Date and time of disclosure (if applicable)

Date and time (or near enough) of disclosure to yourself of the above incident

YYYY

Time

Location of disclosure (if applicable)

Name of discloser (if applicable)

Describe what has happened to cause you concern. If reporting a disclosure, please record what the individual said to you, using their own words or as near as you can remember them.

Name of individual(s) suspected of perpetrating harm *

Name of individual(s) suspected of being harmed *

If different forms of harm are suspected, please complete a separate form for each type of harm.

Name(s) of others present at incident *

Name(s) of others present at disclosure (if applicable)

Describe any actions taken by you since your concern began. Please note anyone/any services you've reported your concerns to. *

Other *

Do you have any other concerns, comments, or questions you wish to raise?

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