Safeguarding Concern Report Form

If the person you’re concerned about is in immediate danger – for example there’s a medical emergency, a risk of injury or a crime is in progress – act straightaway. Call 999 for emergency services.

If there is no immediate danger, please use this form for any concerns you have that a specific child / adult is at risk of harm, abuse or neglect.

Safeguarding Concern Report Form

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Your Name(Required)

First

Last

Your Email Address(Required)

Email Address

Confirm Email Address

The name of the person you are concerned about (if known)

If a child, the name of the child’s parent / guardian (if known)

The date on which your concern was triggered (by what you saw or heard)

All available information about your concern (please include: where, who was involved, what was said by whom, and any action taken by anyone)(Required)

Other details as appropriate / if known to you

Does the child / adult have a disability?

Where does the child / adult live (town/city)?

Were any other organisations involved at the time of the concern? (e.g. Social Services, residential college / home, Hospice / Hospital, Other) (please specify)

Is the child / adult of concern aware of this report?

If the person of concern is aged under 18 years, is their parent / guardian aware of this report?

I consent to SMA UK safely storing and using this contact information so that you can respond to my request. SMA UK will not share my information with any third party unless I give permission or they are required to do so by law. I know I can read more about this in our Privacy Policy

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