Adult Safeguarding Incident Report Form
Use this form to report an adult safeguarding concern or incident, including what happened, who was involved, immediate risk, and any actions taken.
Reporter Details
Reporter’s full name
*
First Name
Middle Name
Last Name
Reporting status
*
Please Select
Staff member
Volunteer
Family member
Other
Job role or relationship to the adult
*
Organization or team
Preferred contact number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Adult at Risk Details
Adult’s Full Name
First Name
Middle Name
Last Name
Preferred Name
Date of Birth (if known)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Living Arrangement or Service Setting
Please Select
Own home
Supported living
Residential care
Family home
Hospital
Temporary accommodation
Other
Communication or Accessibility Needs
Incident Information
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Exact Location of Incident
*
Type of Incident or Concern
*
Please Select
Physical abuse
Emotional abuse
Neglect
Self-neglect
Financial abuse
Sexual abuse
Discriminatory abuse
Domestic abuse
Unsafe environment
Other
Detailed Incident Description
*
Was this Witnessed, Disclosed, or Suspected?
*
Witnessed
Disclosed
Suspected
People Involved and Witnesses
People Involved / Witnesses
*
Relationship to the adult
Relevant contact details (if known)
Is the adult aware of the report?
*
Yes
No
Unsure
Immediate Risk and Actions Taken
Current risk level
*
Low
Medium
High
Immediate danger
Injuries or urgent medical concerns
*
No
Yes
Details of injuries or urgent medical concerns
Actions taken immediately after the incident
*
First aid provided
Emergency services contacted
Supervisor informed
Adult moved to a safer place
Ongoing monitoring
Other
Police or emergency services contacted
*
No
Yes
Details if police or emergency services were contacted
Safeguarding lead or manager notified
*
No
Yes
Details if safeguarding lead or manager was notified
Follow-Up and Submission Details
Follow-up Actions or Support Needed
*
Attachments or Evidence
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Date and Time Report Completed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Reporter Signature or Typed Name Confirmation
Additional Notes
Submit Report
Submit Report
Should be Empty: