Cause for concern form Safeguarding - cause for concern form This form should be used to record concerns about a baby, child or young person. It should be completed as accurately as possible and passed directly to the Designated Safeguarding Officer or their Deputy who should action and then file securely. LLLGB Safeguarding policy and procedures should always be followed. Details of baby, child or young person to whom the concern relates Name Date of birth Address/ contact details Details of the volunteer or staff member raising the concern Name * Contact details Email address * Date report is being made * Date and time of incident Location of incident NATURE OF CONCERN: Provide details of the incident or concerns you have including times, dates, description of any injuries (use body diagram to indicate area of injury), witness details, what you have observed, heard or been told, if the information is first hand, fact or opinion, any other relevant details / information, etc. Ensure you clearly record the voice of the child’s (suggestion - use capital letters to ensure it can be easily recognised). Ensure you act in a timely manner when reporting concerns, especially if there is an injury noted. Please clearly sign and date the record at the end of your statement. AGREED ACTIONS & ANTICIPATED OUTCOMES: Record all discussions, communications, referrals & decisions made. Include details of conversations with parents / other agencies & rationale behind key decision making. Clearly sign & date at the end of the record. If you have any supporting info or a scan of your own notes you'd like to upload, please do so here Drop a file here or click to upload Choose File Maximum file size: 516MB additional file Drop a file here or click to upload Choose File Maximum file size: 516MB additional file Drop a file here or click to upload Choose File Maximum file size: 516MB Submit If you are human, leave this field blank.
