SAFEGUARDING ENQUIRY, NOTIFICATION AND REFERRAL FORM

 

Notes on filling in this form:

1) This form is best filled out on a desktop/laptop computer.  Do not fill it out if other people can see your screen.

2) Please retain a copy of what you type here for your records, and keep it fully confidential.  One way to do this is to download this copy of the form, print it out, and fill it in by hand.
 

Please complete this form when you want to:	Tick as appropriate
• request advice in respect of a generic non-urgent safeguarding matter which is not case specific
• enquire or seek advice about safeguarding training
• notify and refer any allegations, concerns or incident relating to child or adult safeguarding in your church/circuit to the District Safeguarding team
• notify the District Safeguarding team of contact from other agencies regarding adults who pose a risk and/or require safeguarding contracts.
Safeguarding concerns or incidents should be sent to the District Team within 24 hours of receiving the initial information.

 
 

Section 1 - Details of the person completing this enquiry/notification/referral.
Name:
Address:
Tel no:		Email:
Role in the church:
Church:		Circuit:
Date of this enquiry/notification:

 
 

Section 2 - Details of enquiry in relation to a non-urgent safeguarding or training enquiry.

 
 

Section 3 - Case related safeguarding concerns and allegations.
Details of child/adult to whom the notification relates:
Name of child/ren/ adult(s) you have concerns about:
Address and contact details of child/adult:
	Tel no:	Email:
Date of birth of child/adult:
Church where alleged incident took place or with which the above person is associated:
Circuit:

 
 

Section 4 - Nature of concern or incident that has taken place/is alleged to have taken place.

 
 

Section 5 - Action that has taken place to date, including details of other Church officers involved or aware of the concerns, and details of agencies and organisations informed.

 
 

Section 6 - Any additional information which would assist any subsequent enquiries or action which might be required.  (This might include information about the person’s role in the church, information about any previous concerns, details of family and support networks and potential impact of the concern/allegation.)

 

Before sending please ensure you have a copy of what you entered here for your records, and keep it fully confidential.