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)

Concern Form
Your Name  
Your Job Title  
Your Contact Telephone  
Your Work Base  
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



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