Safeguarding Policy/Child concern form

Name of Child:

Age:

Child’s Address:

Name of Parent/Carer:

Telephone no:

Is the person making this report expressing his/her own concerns or passing on those of someone else?

What is said to have happened or what was seen?

When and where did it occur?

Has the child been spoken to? If so, what was said?

Who else, if anyone, was involved and how?

What was said by those involved?

Were there any obvious signs, e.g. bruising, bleeding, changed behaviour?

Has anybody been alleged to be the abuser?

Have the child’s parents been contacted?

Who else has been told about it and when?

Signed………………………………… Date………………. Print Name …………………………………………………….