Safeguarding Concern Form
Safeguarding Concern Form
Please complete this as soon as possible after the incident has occurred.
This form is to record any reports, concern, accidents or near misses.
You should complete the form to the best of your knowledge. This document is restricted once completed and should be stored and exchanged securely. All forms are to be forwarded once completed as a matter of urgency to Julie Hickin, Designated Safeguarding Lead for Newcastle City Learning.
Please note this is a recording form and does not replace the referral forms (if required) to children’s and Adult Social Care (all agency referral form and SAMA1 form respectively)
Type of incident:
Safeguarding: Yes/No (if so, please complete SAMA 1 form if appropriate)
Other: (please state)
Your Name | |
---|---|
Your Job Title | |
Your Contact Telephone | |
Your Work Base | |
Date | |
Child(ren) or Vulnerable adult(s) Name(s) | |
Child(ren) or Vulnerable adult(s) Age(s) | |
Child(ren) or Vulnerable adult(s) Gender(s) | |
Child(ren) or Vulnerable adult(s) Date(s) of Birth | |
Child(ren) or Vulnerable adult(s) Address(es) | |
Contact Telephone | |
Details of allegations / suspicions / reports / incidents witnessed |
Be as factual as possible and include any action immediately taken
|
Details (continued) |
Continue on a separate sheet if necessary |
Signature | |
Date |
Referral Code (Please tick the relevant box below)
Referral Code | Description | Tick |
---|---|---|
Urgent | Potential safeguarding or immediate concern. Inform Designated Safeguarding Manager immediately (0191 277 3520) | |
Concerning | Consideration required as to whether learner is referred for Behavioural Support | |
Information Gathering | To be filed and copy sent to Designated Safeguarding Person |
Completed By Date
Received / Actioned by Date