Safeguarding Report Form
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Name of person completing form
Email of person completing form
Date form completed
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/
DD
/
YYYY
Date, time and location of incident
Age category of person you are reporting safeguarding concern *
Staff present during incident, including partner agencies
Name, age (DOB if possible), gender, and all contact details person report of concern is about
Parent / carer / guardian's details (including partner org/teacher/social worker if more appropriate)

Description of the incident or concern: Include relevant information such as what happened and how it happened, description of any injuries sustained, behaviour witnessed and whether the information provided is being recorded as fact, opinion or hearsay 

Details of any previous concerns, incidents or relevant safeguarding records: 
Child, young person or adult at risk account of the incident or concern: (use their own words)

Witness account of incident or concern: (include witness contact details and name and their relationship to individual at risk)

Details (if relevant) of any persons involved in the incident or alleged to have caused the incident, injury or presenting risk (name, address, contact, age)
What actions have taken place already
What would you like to see followed up by the DSL (please note, the DSL will also make their own assessment and action plan and update you wherever appropriate)
After reflecting on the incident, is there any learning for Odd Arts or our staff so we can do things better in the future? *
If you are the Designated Safeguarding Lead please complete.  If you are not the DSL please submit the report without categorising.
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