Child Safeguarding Incident Report Form
Use this form to report a child safeguarding concern and record the key details, people involved, immediate risk, and actions taken.
Reporter Information
Reporter's Full Name
*
First Name
Last Name
Role / Relationship to the Child
*
Please Select
Parent/Guardian
Teacher
School Staff
Healthcare Professional
Social Worker
Neighbor
Family Member
Other
Organization or Department (if applicable)
Preferred Contact Method
*
Phone
Email
In-Person
Incident Details
Incident date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident time
*
Hour Minutes
AM
PM
AM/PM Option
Location of incident
*
Type of concern
*
Physical harm
Emotional harm
Neglect
Sexual abuse
Exploitation
Unsafe environment
Other safeguarding concern
What happened?
*
Child and Immediate Action
Child's Name or Identifier
Child's Age
Immediate Risk or Injuries Observed
Actions Taken Immediately After the Incident
Submit Report
Should be Empty: