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4. School Concerns Form

Education settings must ensure that volunteers, staff and governors are able to record concerns about:

  • The welfare of a child or young person; and
  • The behaviour of a volunteer, member of staff, governor or person connected with the school.


The following headings illustrate the minimum information that should be included in the local arrangements that is agreed within the individual education setting.



A statement should be included on the form used in the setting that confirms:


"Any member of the school staff, including volunteers, must record any concerns about a child or young person. This form must be completed as soon as possible after the discovery of the concern and send to the Designated Safeguarding Lead (DSL). If the concerns are immediate, please tell the DSL straight away."


Concerns about a child or young person


Child's name:



Date of Birth:




Concern identified by:




Date of concern:


Time of concern:




Place of incident:



Name of alleged person (s) responsible for the harm

Not Known



Pupil in this school/college


Pupil in another school/college (Please specify)


Family member






Member of staff







(Please specify)


Please Note: A copy of this record must be kept on the personnel file for any volunteer, member of staff, governor or person connected with the school



Concern/Incident/Disclosure: Why are you concerned about this child? What have you observed and when? What have you been told and when?

Please provide a description of any incidents or anything you have been told by a child, or another person. Remember to make clear what is fact and what is hearsay/opinion. Note the language/terminology used by the child, or adult, and be clear about who has said what. Continue on a separate sheet if necessary.














Has any action already been taken in relation to this concern?

For example child taken out of class, first aid



Name of person concerns reported to





Action to be taken / recommendations from DSP



Name of person completing form


Date and time