Confidential incident/concern form

Please complete this form as fully as possible, answering all sections relevant to your circumstances.

All fields marked with an asterix require a response. If this field is not applicable to your circumstances please just respond 'Not applicable'.

Your Name *

Your phone number *

Your email address *

Your role / postition / link to incident

Which church community does the issue relate to? *

Does the concern relate to a parish priest, volunteer or staff member? *

Details of person causing risk to others (include name) *

Details of person or persons at risk (include name(s)) *

What date did the issue of concern occur or become known? *

Is person you are concerned about: *

18 years old or under

an adult with vulnerability

Contact details of person experiencing, or at risk of, abuse or neglect

Please in your own words provide us with a summary of the situation that is of concern. Please try to include any dates, names or details that will assist (this box can be dragged to be bigger)

Please tell us if you have already spoken to any of the folowing regarding this situation: *

Child/adult experiencing or at risk of abuse or neglect

A parent/guardian/carer

Senior staff/line manager

Social Services

Police

Probation

Other

If you have already discussed with another agency, please provide the name and contact number of any professionals involved:

* Required Fields

Page last updated: Thursday 30th March 2023 1:57 PM