Cause for Concern Form
Do not discuss with anyone else (including parents/guardians and group leaders) except the Safeguarding Leaders.

  1. What constitutes a safeguarding concern? – anything that has caused you to question the safety or general wellbeing of a child, however small. 
  2. Why do you need information regarding ‘other household members’? (question 7 below) – It is important to include information about significant adults in the household especially when concerns relate to children. 
  3. Why is the view of the child/adult significant? It is important to give whatever detail is available of the child or adult’s explanation (or verbatim) of the matter to help ascertain if it is plausible and to help offer a context to the concern identified.
  4. Passing information to the Safeguarding co-ordinator – Your safeguarding co-ordinator holds ultimate responsibility in responding to any safeguarding concerns within New Community Church and therefore it is important that they have oversight of the actions being taken and make relevant and appropriate contact with statutory agencies if required. They will remain the most appropriate link between the organisation and external agencies.
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1. Your Name: *
2. Your Role / Job title *
3. Child's name (subject of concern): *
4. Date of Birth / Age: *
5. Date of concern: *
6. Time of concern: *
7. Other members of the household (if known, refer to point 2 above) *

8. Record the following factually: Nature of concern, e.g. disclosure, change in behaviour, demeanour, appearance, injury, witnesses etc. (please include as much detail in this section as possible. Remember – the quality of your information will inform the level of intervention initiated.) 

9. How did the concern come to light? *
10. What is the child saying about what has happened? (refer to point 4 above) *
11. Any other relevant information. Previous concerns etc. *
12. Date and time of discussion with Safeguarding Co-ordinator (see point 5 above)
13. Declaration *
14. Signed: *
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