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FORM01
Safeguarding Concern / Referral Form
For recording and referring safeguarding concerns to the Designated Safeguarding Lead.
Concern Details

Date and Time of Concern: [Date and Time of Concern]

Person Reporting (Name & Role): [Person Reporting (Name & Role)]

Person Concern Relates To: [Person Concern Relates To]

Date of Birth of Subject: [Date of Birth of Subject]

Nature of Concern: [Nature of Concern]

What Was Observed, Heard or Said (verbatim where possible): [What Was Observed, Heard or Said (verbatim where possible)]

Immediate Action Taken: [Immediate Action Taken]

Referral Decision

DSL Name: [DSL Name]

Decision (monitor / seek advice / refer): [Decision (monitor / seek advice / refer)]

External Referral Details: [External Referral Details]

Date of Referral: [Date of Referral]

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Safeguarding Concern / Referral Form

For recording and referring safeguarding concerns to the Designated Safeguarding Lead.

⚠️ Fill in your details below. Download a pre-branded PDF version of this form for use in your service.
Organisation Details
Concern Details
Referral Decision

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