MMOV - Safeguarding Incidents/ Concerns

Safeguarding Incidents/ Concerns

Tell us what happened in the form below.
Staff, Volunteers and regular visitors are required to complete this form and pass it to the Designated Safeguarding Lead, if they have a safeguarding concern about a child.
Please use this form to record incidents or concerns of abuse or neglect of children and vulnerable adults. It is important that we maintain local and national records to pass to local safeguarding agencies such as Social Service and the Police.

These records will also be used to produce an annual report on Safeguarding for Mighty Men of Valour governing body.
Frederick Clarke is the Designated Safeguarding Lead (DSL)

Mobile: 07858 770 779

Email: mightymenofvalour@live.co.uk
Staff Full Name*
Full Name
Staff Position/Role*
Date of this Report*

DayMonthYear
Date
Name of Child or Vulnerable Adult*
Child's Date of birth

DayMonthYear
Date
Location of incident *
Location of incident or concern
Time of Report*

:HourMinutes
Main contact details of Child/Adult (if possible)*
Body Maps

These body maps are not a subsitute for a medical report/map by a paediatrician. they are intended as as optional tool to help indicate the place, size and severity of any physical injures observed.

The child must not be examined in order to complete these and should be referred to a paediatrician if there are any suspicious marks.
Drawer in box below, where you have identified any injuries to child?
Please indicate:

1. Time and date of the incident/disclosure

2. Where were you when the child made a disclosure

3. Concern or Incident

4. What you saw

5. Who else was there

6. What did they child say or do, and

7. What you said
1. Time and date of the incident/disclosure*
2. Where were you when the child made a disclosure*
3. Concern or Incident*
4. What you saw*
5. Who else was there?*
6. What did they child say or do, and*
7. What you said*
Potential Witnesses:*
Action taken by you:*
Give additional comments which you believe will be important during further investigations of complaint:
By signing you declare that all information you have given here is truthful and accurate.
Signature (Person Disclosing Safeguarding incident)*
Date of Signature*

DayMonthYear
Date
The rest of this form to be complete by DSL

Name of Designated Safeguarding Lead (DSL):

Frederick Clarke
Designated Safeguarding Lead Officer comments/ Actions:
Time report received

:HourMinutes
Date of Safeguarding Incident

DayMonthYear
Referred to...

PoliceChildren ServicesTeacherOther
Referred to LADO

YesNo
Parents or Carer informed? Yes or No

YesNo
If no, state why Parent/Carer was not informed?
Feedback given to....

ChildParent/GuardiansPerson who recorded the disclosureThe person who made the referralOther
Further action Agreed:
Name: Frederick Clarke
DSL Printed Signature
DSL Signature
Date of Signature

DayMonthYear
Date
Should be Empty: