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Safeguarding Disclosure

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 ([email protected]) within one day of the incident.
In case of emergency, do not delay in contacting emergency services.

Details of Child/Adult

Name

Date of Birth

Gender

Gender
A
B

Details of Incident/Concern/Disclosure

Name of the Programme

Location Address

Location Region

The region where this event is physically taking place in.

Date of Incident

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

Other Supporting Documents

Handwritten notes, any other documented relating to this incident can be attached here for the record.

Your Details

Your Full Name

Your Email

Your Phone Number

Your Role

Your Signature

Signature