Child Safeguarding Incident Record Sheet
Section 1: Details of Child
Child's Name:
Date of Birth:
Gender:
Address:
Section 2: Incident Details
Date of Incident:
Time of Incident:
Location:
Details of Incident:
Section 3: Reporting Person
Name:
Role/Relationship to Child:
Contact Details:
Section 4: Action Taken
Immediate Action Taken:
Person(s) Notified (with Date/Time):
Section 5: Additional Notes
Other Relevant Information: