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Concern Recording Form

This form must be completed as soon as possible after receiving information that causes a concern.  Contact the Child Wellbeing and Protection Officer on 07856 728634 to report the concern then email the completed form to as soon as possible after completion; do not delay by attempting to obtain information to complete all sections. 


Part A – Contact Information

Please complete Part A to include all relevant contact information.  Where the concern is about a child and the conduct of an adult relating to that child then both parties information must be completed.  You must also include your contact information.

Part B – Details of the Concern

Please complete this section to include as much information as possible. Where possible please include information about dates, times and location. If the concern has been reported to you by the child, please use their own words and also record anything that you said to the child.

Part C – Information Sharing

Please complete this part of the form if you have shared the information with any third party including the child’s parents/carers, Named Person or with other services including the police, social services, school or any other relevant organisation

Remember to maintain confidentiality on a need-to-know basis – do not discuss this incident with anyone other than those who need to know.

Part D – For use by the Child Wellbeing and Protection Officer

This section is for use by the Child Wellbeing and Protection Officer and should not be completed by the person reporting the concern.


Please do not keep any electronic, printed or written versions of this form.  It is important to maintain confidentiality to delete or shred as soon as the information has been passed on. This information will be retained by the Child Wellbeing and Protection Officer in a secure and confidential manner.

A Concern Recording Form can be downloaded by clicking on the following link and then click on Club Templates.