Child concern form - Muslim Youth Network

Details of Child, Parents and Carers

Name of child

First Last

Gender

Male

Female

Age

Date of Birth

Ethnicity

Language

Additional Needs

Address

Name/s of Parent/Carer

Staff details

Name

First Last

Position

Date of Incident

Time of Incident

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

Reporting own concerns

Responding to concerns raised by someone else

Their name within the club/groups/organisation.

Their position within the club/groups/organisation.

Have you informed the statutory child protection authorities?

Have you informed the Police?

Yes

Date

Time

Name and phone number of the person you spoke you spoke to:

Have you informed Social Services:?

Yes

Date

Time

Name and phone number of the person you spoke you spoke to:

What is the action agreed with child protection authorities:

What has happened since referring to statutory agencies? Include the date and nature of feedback and outcome of referral.

If the concerns are not about child protection, details of any further steps taken to provide support to child and family, and any other agencies involved.

Child concern report form

Details of Child, Parents and Carers

Staff details