Safeguarding Disclosure Form
This form should be used to record any safeguarding concerns in relation to a child or vulnerable adult. All information must be treated as confidential and passed onto the National Safeguarding Board (safeguarding@jesusyouth.co.uk) within one day of the incident.
In case of emergency, do not delay in contacting emergency services.
Details of Child/ Adult
| Field | Details |
|---|---|
| Name | |
| Date of Birth | |
| Gender |
Details of Incident/ Concern/ Disclosure
(Continue on a separate sheet if necessary)
| Field | Details |
|---|---|
| Name of the Programme | |
| Location | |
| Date and time of incident | |
| Method of disclosure |
Details of incident
Outline the incident or concern. If a disclosure has been made, state what was said (in as much as possible in the child’s own words) and how you responded. For concerns, detail what you have seen/been told, that makes you believe the child is being abused or is at risk of abuse.
Reported to
Full name & contact details, including context and background of disclosure
Names of other adults present and their roles
Names of other children present
Form completion details:
(All records, including hand written notes, should be kept with this document)
| Field | Details |
|---|---|
| Completed by | |
| Role | |
| Signature | |
| Form completion date |