Safeguarding reporting form This information will be handled sensitively by Diversity Role Models' Safeguarding Team. Your name (the person reporting the concern/incident) Today's Date Time and Date of Incident Details of concern/disclosure: (optional) Describe the issue fully including names, reported allegations, observations of behaviour, injuries, where you were when the child made a disclosure, what you saw, who else was there, what did the child say or do, what you said, etc. Please ensure that if there is an injury this is recorded (size and shape). Please make it clear if you have raised a concern about a similar issue or the same person(s) previously. Action taken: Please include who you have spoken to and their position e.g. Designated Safeguarding Lead (DSL) Your email address You telephone number Verification