This form should be used to record safeguarding concerns. In an emergency please do not delay in informing the police or social services. All the information will be treated as confidential. Please complete the form as fully as possible.

Your details - the person completing the form

Full Name *

First name *

Please enter a First name

Middle name(s)

Surname *

Please enter Surname

Telephone Number *

Please enter some text

Email *

Please enter a valid email

Are you a Church member? *

Yes

Please select at least one of the options

Details of the person affected

Full Name *

First name *

Please enter a First name

Middle name(s)

Surname *

Please enter Surname

Parent/Guardian (If appropriate)

Please enter some text

Telephone Number

Please enter some text

Please enter a valid email

Address

Address 1

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Address 2

Please enter some text

Address 3

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Town

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County

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Postcode

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Country

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What relationship are they to the Church?

Member

Visitor

Contractor

Other

Please select at least one of the options

Details of the incident (please describe in detail using only the facts)

Comments *

Please enter some text

Other present or potential witnesses

Additional relevant information (please detail anything else that you believe helpful or important)

I have completed this form and provided information that is factual and does not contain my own view

If in doubt about anything then please contact the Parish Safeguarding Officer.