Safeguarding - www.ANChome.co.uk

Once you have completed this form, it will be stored and processed inline with the Safeguarding Policy.

If you would like to speak to someone - please reach out to a member of the safeguarding team or email admin@anchome.co.uk

Please be sure to give factual information. The name & date of birth of the person of concern is important.

Full Name of person reporting

E-mail of person reporting

Phone Number of person reporting

Who is this concern about?*

What is their Date of Birth - if known

Have you disclosed this concern with anyone else within the church? If so, please specify*

Date of concern / disclosure raised*

Date of concern / disclosure raised

Please state below what was said, any concerns you had and what you observed in as much detail as possible

Prompts: What are your reasons for concern, details of disclosure, were any witnesses or others involved.*

Actions taken at tht time?*

Have you contacted outside agencies? - police, social care. Please state contact person and details.*

Please write your name below to sign that this is an accurate recording of the concern*