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Safeguarding Concerns Questionnaire

Date Form Completed:

Name of Person Raising Concern/s: *

First

Last

Name of Person whose conduct gave rise to Concerns Regarding Safeguarding: *

First

Last

Name of Person Completing This Form: *

First

Last

Work Email of Person Completing This Form: *

Reason/s For Concerns:

Are concern/s raised because of…

A single incident
A pattern of conduct
Some other reason

On or around what date was the Person Raising Concerns first aware of the Concerns Regarding Safeguarding?

Are the Concern/s Regarding Safeguarding:

directly related to the employee’s duties or position, or
something that has arisen peripheral to their employment

Describe All Incidents said to give rise to the Concerns Regarding Safeguarding:

It is essential to include: (i) location of incident/s, (ii) date/s or if specific dates cannot be provided, approximate dates (i.e. on or around [date]), (iii) identify of any witnesses, (iv) exactly what the employee did, or failed to do.

Severity and Impact

Concern/s the following

Did the Incident/s regarding the Concerns Regarding Safeguarding:

Cause physical harm, or
Cause emotional harm, or
Constitute a ‘near miss’ in terms of harm
Disclose an attitude on behalf of the employee that could cause or contribute to harm

If Physical or Emotional Harm was caused, describe the harm that resulted:

Actions Taken

Did any of the following happen a result of the Incident/s that give rise to a Safeguarding Concern:

Internal investigation by employer
Report to Local Authority Designated Officer (LADO)
Report to Police Authority
Disciplinary Procedure Followed
Dismissal of Employee
Legal Claim against Employee
Referral to Care Quality Commission

If 'Yes' give date/s of key events, names of those involved and dates or approximate dates:

What is Employer's assessment of the risk posed by the Employee toward vulnerable children or adults:

High risk of serious harm
Medium risk of serious harm
Low risk of serious harm
Some risk of harm but not serious harm
No risk of harm but training on standards required