Incident Report Form

Contact information (you):

Address:
Postcode:
Telephone numbers:
Email address:

Child's gender:

[   ]   Male
[   ]   Female

Parent's / carer's name(s):

Have parents / carers been notified of the incident?

[   ]   Yes
[   ]   No

If YES, please provide details of what was said / action agreed:

Are you reporting your own concerns or responding to concerns raised by someone else?

[   ]   Responding to my own concerns
[   ]   Responding to concerns raised by someone else.

If responding to concerns raised by someone else, please provide further information below:

Please provide details of the incident or concerns:

Include other relevant information, such as description of any injuries and whether you are recording this incident as fact, opinion or heresay.

Please provide the child's account of the incident:

Please provide any witness accounts of the incident:

Please provide details of action taken to date:

Has the incident been reported to any external agencies?

[   ]   Yes
[   ]   No

If YES, please provide further details:

Name of organisation / agency:
Contact person:
Telephone numbers:
Email address:
Agreed action or advice given: