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.
PART A – WHERE THERE ARE CONCERNS ABOUT THE WELLBEING OF A CHILD
(SAFE, HEALTHY, ACTIVE, NURTURED, ACHIEVING, RESPECTED, RESPONSIBLE, INCLUDED)
- Child’s Details
|Name||Date of Birth|
|Address Post code||Telephone Number|
|Childs Named Person||Named Persons Telephone Number|
|Preferred Language||Is an interpreter required? YES / NO|
|Any Additional Needs|
2. Details of situation giving rise to concerns – including date, time, location, nature of concern, who, what where, when, why.
3. Details of any witnesses/other people involved including names, addresses and telephone contacts.
4. Details of injuries – including all injuries sustained, location of injury and action taken.
5. Child’s views the situation (if expressed)
PART B – WHERE THERE ARE CONCERNS ABOUT THE CONDUCT OF AN ADULT
6. Details of adult where there are concerns about their conduct
|Address Post code||Relationship to child|
7. Details of concerns – including date, time, location, nature of concern, who, what, where, when, why, continue on a separate sherif necessary.
8. Details of any action taken
9. Details of agencies contacted – including date, time, name of person contacted and advice received
10. Have the child’s parents/carers been informed? YES / NO (delete as appropriate) If yes, record details / if no, please state why not
PART C – YOUR CONTACT INFORMATION
11. Details of Person Recording Concerns
|Address Post code||Position / Role|