Appendix 8: Safeguarding incident recording form
Safeguarding Incident Recording Form
_________________________________________________________________________
Basic information:
● Full name of child, young person or adult concerned:
● Address (including postcode):
● Email address:
● Telephone Number:
● Date of birth:
● Date and time of incident:
● Location of incident:
● Other people present (witnesses):
_________________________________________________________________________
Record of incident (continue on a separate sheet if necessary):
Please ensure you are as accurate and detailed as possible. Use quotes wherever possible – do not interpret what was said using your own words.
Include details such as tone of voice, facial expression and body language. Record what you said as well as what the child, young person or adult said.
If you have formed an opinion please state it, making it clear that it is your opinion and give reasons for forming that opinion.
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_________________________________________________________________________
Who has been spoken to about the incident?
● Position / Organisation:
● Name:
● Email:
● Telephone Number:
● Church Safeguarding Coordinator:
● Synod Safeguarding Officer:
● Children’s Services Adult Services:
● Police:
● NSPCC
● Parent / Carer:
● Other (please state role and organisation):
_________________________________________________________________________
Feedback and follow up actions (continue on a separate sheet if necessary):
Name (person who completed this report):
Position held in the church:
Signed:
Dated: