Safeguarding Form

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Timestamp
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Hour
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Minutes
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Due date
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Is someone in immediate danger or do you need support right away?* This field is required.
YESNO
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End this form immediately and call 999
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Is this a whistleblowing complaint about someone in a position of leadership within the church?* This field is required.
YESNO
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Please email your concern to safeguarding@blackburn.anglican.org
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Is this about something that happened at Blackpool Church?* This field is required.
YESNO
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Is this about someone who attends Blackpool Church services or activities?* This field is required.
YESNO
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Please log this concern with the police by calling 101 or the most relevant body to the concern e.g. a school or charity
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Are you concerned that someone has been harmed or might be at risk of some type of harm?* This field is required.
YESNO
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What type of harm has the person disclosed or is at risk of?* This field is required.Tick all that apply
Physical Abuse
Emotional Abuse
Sexual Abuse
Domestic Abuse
Neglect (incl. youth homelessness)
Self Harm/Suicide
Criminal Activity (e.g. knife crime)
Financial Abuse
Other
I don't know
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Other* This field is required.
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This is unlikely to be a safeguarding issue. Consider logging it as a pastoral concern here or start again.
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Your Name* This field is required.
First Name
Last Name
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Your Email
example@example.com
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Your Phone Number
Please enter a valid phone number.
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The full name of the person at risk* This field is required.
First Name
Last Name
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Is the person at risk...* This field is required.
An Adult
Secondary School/College Aged
Primary School Aged
A Baby/Nursery Aged
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Trello Label
Youth
Kids
Adult
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Their date of birthLeave blank if unknown or estimate a date if only roughly known
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Their addressLeave blank if unknown
Street Address
Street Address Line 2
City
County
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Their parent/carer's nameLeave blank if unknown
First Name
Last Name
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Their parent/carer's phone numberLeave blank if unknown
Please enter a valid phone number.
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The full names and details of anyone else involved
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Are any other professional/charity services already involved in this situation?* This field is required.
Police
GP or A&E
Mental Health Crisis Team
Social Services
School/College/University
Other
No
I don't know
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Other* This field is required.Describe the services you mean by 'other'
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In your opinion, what is the likelihood of the harm happening/happening again?0 - very unlikely, 10 - very likely (If you're struggling to choose, ask yourself "Is it a 10?" or "Is it a 0?")
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In your opinion, what severity of harm has taken place or might take place?0 - very minor, 10 - life threatening (If you're struggling to choose, ask yourself "Is it a 10?" or "Is it a 0?")
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When did the event described take place?Try to estimate a date if exact dates are unknown
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Year
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Hour
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Minutes
AM
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PM
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Please describe the concern you have in as much detail as you can* This field is required.Try to include a quote of the most concerning sentence you heard with as much accuracy as possible
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Have you already done anything to try to resolve the situation?
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Is there anything else you would like to add?
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Summary for Trello
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The details in this form are accurate to the best of my knowledge* This field is required.Sign below
Clear
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