ICF Initial Safeguarding Incident Report Form

CONFIDENTIAL WHEN COMPLETED

Person Reporting

Name

Phone Number

Email Address

ICF Role

Nature of Report

Reporting a disclosure by a child

Reporting a disclosure by a youth

Reporting a disclosure by a vulnerable adult

Reporting someone else’s concerns

Reporting my own concerns

Reporting an incident I witnessed

Description of the Safeguarding Incident or Concern (Provide comprehensive details, including names, locations, dates, injuries, behaviours witnessed, words spoken, full nature of incident or concern)

Signature

Date

Report Received By:

Signature and Name

Date

ANNEX 6: STEP 1 - ICF INITIAL SAFEGUARDING INCIDENT REPORT FORM