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Safeguarding
Name
Email
Phone number
Is the person you are raising a concern about family, volunteer, staff or other?
Family
Volunteer
Staff
Other
Are they a family we are supporting?
Yes
No
Please provide the full name and address, telephone number of family, date of birth of child and siblings
The names of professionals known to be involved with the child/family eg: GP, health visitor, school
What was the date and time of your concern?
Please record an account of what you heard or witnessed. Be as factual as possible. State where it occurred and what happened including exact wording used by the child or adult. Use direct quotes (“”) where possible.
Does the child need urgent action to make them safe?
Write the names and contact details of any witnesses to what you saw or heard.
Has consent for a parent with parental responsibility been given to the referral being made?
Yes
No
Have you discussed this with anybody else, for example the designated safeguarding lead?
Yes
No
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