Annex 6

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