CONCERN RECORDING FORM
This form must be completed as soon as possible after receiving information that causes a concern. Contact the Child Wellbeing and Protection Officer on 07759753425 to report the concern then email the completed form to firstname.lastname@example.org as soon as possible after completion; do not delay by attempting to obtain information to complete all sections. Please do not keep any electronic, printed or written versions of this form. It is important to maintain confidentiality to delete or shred as soon as the information has been passed on.
Complete Part A where the concern relates to the wellbeing of a child and/or Part B where the concern relates to the conduct of an adult. Finally, complete Part C to provide your contact information.
Girvan Football Club – CONCERN RECORDING FORM
ADVICE FOR COMPLETING THE FORM
Part A – Contact Information
Please complete Part A to include all relevant contact information. Where the concern is about a child and the conduct of an adult relating to that child then both parties information must be completed. You must also include your contact information.
Part B – Details of the Concern
Please complete this section to include as much information as possible. Where possible please include information about dates, times and location. If the concern has been reported to you by the child, please use their own words and also record anything that you said to the child.
Part C – Information Sharing
Please complete this part of the form if you have shared the information with any third party including the child’s parents/carers, Named Person or with other services including the police, social services, school or any other relevant organisation
Remember to maintain confidentiality on a need to know basis – do not discuss this incident with anyone other than those who need to know.
Part D – For use by the Child Wellbeing and Protection Officer
This section is for use by the Child Wellbeing and Protection Officer and should not be completed by the person reporting the concern.
Please do not keep any electronic, printed or written versions of this form. It is important to maintain confidentiality to delete or shred as soon as the information has been passed on. This information will be retained by the Child Wellbeing and Protection Officer in a secure and confidential manner.
PART A – CONTACT INFORMATION
CHILD’S DETAILS (if applicable – details of the child who has been harmed or is at risk of harm)
|Name:||Date of Birth:|
|Address: Post Code:||Tel No:|
|Child’s Named Person/school teacher:||Named Person/school teacher Tel No:|
|Preferred Language||Is an interpreter required? YES / NO|
|Any Additional Needs?|
ADULT’S DETAILS (if applicable – adult whose conduct you are concerned about)
|Address: Post Code:||Relationship to Child:|
CONTACT INFORMATION OF PERSON REPORTING THE CONCERN
PART B – DETAILS OF THE CONCERN
If necessary please continue on a separate sheet. If doing so please number and date each sheet.
|Details of concern:|
|Child’s views on situation (if expressed). Where possible, please use the child’s own words|
|Details of any other witnesses/other people involved|
|Details of any injuries (where applicable) Please include all injuries sustained, location of injury and any treatment|
|Action taken so far and when:|
|Other relevant information:|
PART C – INFORMATION SHARING (if applicable)
PLEASE NOTE – it will usually not be necessary to share information before seeking advice from the Child Wellbeing and Protection Officer, except in an emergency. Only share information on a need to know basis. If you are unsure as to who you should inform, please contact the Child Wellbeing and Protection Officer for further advice
|Who has been informed?|
|Child’s parents/carers Yes/No||If yes, record details: If no, please state why?|
|Child’s Named Person/school teacher Yes/No||If yes, record details: If no, please state why?|
|External agencies contacted (date and time)|
|Police Yes / No Date: Time:||Name, role and contact number: Incident number (if applicable): What information was shared and why: Details of advice received:|
|Local authority (inc. social services and education) Yes / No Date: Time:||Name, role and contact number: What information was shared and why: Details of advice received:|
|Other Yes / No Date: Time:||Name and contact number: What information was shared and why: Details of advice received:|
PART D – FOR CHILD WELLBEING AND PROTECTION OFFICER
|Information Shared with any third party e.g. Scottish FA, Affiliated National Association etc.|
Reason for closing concern:
Signed _____________________________________ Date: ____________________