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Protect and Teach Safeguarding Concern Reporting Form
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Section 1 – Name Of Person Completing This Form
*
First
Last
Your Email
*
Your Contact Telephone Number(s)
Your Role/ Your relationship to the concern
Parent/ Carer
Teacher
School Staff
Volunteer
Professional/Organisation
Trustee
Member of the Public
Other
Person Completing This Form
Date and Time (Of Concern and Form Completion)
*
Section 2 – Name Of Person at Risk/ Person You Are Concerned About (if known)
*
First
Last
If the identity is unknown, record as much identifying information as possible.
*
Approximate Age (if known) School / Organisation (if known) Location (Town / Area)
Section 3 – Nature of Concern. What are you concerned about? (Tick all that apply)
*
Physical abuse
Emotional abuse
Sexual abuse
Neglect
Online harm/abuse
Child Criminal Exploitation
Child Sexual Exploitation
Domestic abuse
Bullying
Radicalisation
Financial abuse (Adults)
Self-neglect (Adults)
Other/Unsure
Section 3 – Nature of Concern (Other/Unsure)
Relevant Details
Section 4 – Details of Concern. Please describe your concern.
*
Record FACTS ONLY. Write down ALL the details you are aware of relating to your concern. (Include dates, times, locations and names if known. Please provide factual information wherever possible.) Record exactly: What was seen – What was heard – What was reported – Use the person’s own words wherever possible. Do not include personal opinions. Do not investigate the concern yourself. If there is an immediate risk of serious harm, contact the emergency services (999) before completing this form where appropriate.
Section 5 – Immediate Risk. Is the person currently at immediate risk?
*
— Select Choice —
YES
NO
UNSURE
7 Section Other
Section 5 – Have emergency services already been contacted?
*
— Select Choice —
YES
NO
Section 5 – Immediate Risk (If YES) Please provide details.
If you answered YES to the Section 5 questions. Please complete this section. Provide as much information as possible (any reference numbers or contacts).
Section 6 – Other Agencies. Have any of the following already been informed?
*
Police
Children’s Social Care
Adult Social Care
School
College
Other Educational Institution
Employer
NSPCC
Other
Don’t Know or N/A
Please Tick ALL that apply.
Section 6 – Other Agencies
*
Please provide details.
Section 7 – Additional Information
*
Is there anything else you would like us to know? Please provide details.
Section 8 – Consent
*
I confirm that the information I have provided is true to the best of my knowledge.
I have read the Protect and Teach Privacy Notice.
CLICK HERE FOR Protect and Teach Privacy Notice LINK: https://protectandteach.org/
Submit
Click
HERE
for the Protect and Teach
Privacy Notice
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