Bound Book Reference Number:

Notice of Concern / Incident Form	Insert School Logo School name
Child’s Name:	Class:
Date of incident:	Time of incident:
This form must be completed, signed and dated by any member of staff who identifies a possible child protection or safeguarding concern: All child protection concerns must be reported immediately to the designated Safeguarding Lead. Record the facts and do not make judgements. Record dates, times, places, actual words, what was observed, who was present and questions asked. Any concerns about staff should be reported directly to the Head Teacher/Head of Service. Concerns about the Head Teacher should be reported to the Chair of Governors/Proprietor
Details of Concern/Incident:
Immediate Actions by staff:
Signed: Print:	Date:
Action taken by Designated Safeguarding Lead: based on Bond T, (2000) 223-236 Brief summary of concern: Which agency is needs to lead on this issue: School/Children’s Social Care/ Police/Health/ Other If School – who will lead on this? Which guidelines and policies need to be considered: Which potential courses of action are open to this concern: Which course of action are you going to take:
Any other relevant information:
Signed: Print:	Date:
Evaluate Outcome of actions:	Bound Book Reference Number: Linked incidents
Right Services Right Time
Universal
Universal+
Additional
Complex/Significant
Nil Action needed	Incident Record	Early Help	Health & Safety	Request 4 Support