Child Safety Incident Report Form • Beaconsfield Baptist

Complete this form within 24 hours. Record facts only (who, what, when, where). Avoid opinions. Use direct quotes where possible.

1. Report Details

Date of Report *

Time of Report *

Report Completed By (Name and Role) *

Contact Details *

Completed within 24 hours

If not completed within 24 hours, please explain the delay.

2. Person(s) Involved

Child / Young Person

Name *

Age

Gender *

Parent / Carer Name(s) *

Contact Details *

Person Reporting (if different)

Name

Role

Contact Details

Person Subject Of Concern

Name *

Role / Relationship to child *

Other Persons / Witnesses

Names and Roles

3. Incident / Concern Details

Date *

Time *

Location *

Description (factual, chronological) *

Include direct quotes where possible. Do not include assumptions or conclusions.

4. Immediate Response

Child in immediate danger.

Actions taken to ensure safety

What the child said (use their words)

5. Internal Reporting

Safe Church Person notified (name and date) *

Child Safety Deacon notified (name and time) *

6. External Reporting

Police

Police details (date/time/reference)

Child Protection (DFFH)

Child Protection (DFFH) details (date/time/reference)

CCYP

CCYP details (date/time/reference)

Other

Other details (date/time/reference)

7. Declaration

Name *

Date *