Child Protection Referral Form

To be completed by the Designated Lead for Safeguarding in conjunction with the member of staff raising the concern. This information should be shared with the relevant agencies by telephone as soon as possible after being alerted of the concern, and must be followed up in writing within 48 hours. Note: If the child is perceived to be at risk of immediate significant harm, the police should be contacted immediately.

Details of Child

Name: / Date of Birth:
Address: / Telephone number:
Does the child have any specific needs? Yes/No
If yes, please specify…
Is the child known to be subject to any of the following? / Child Protection Plan ¨
Child in Need Plan ¨
Education Health Care Plan (EHCP) ¨ Looked After Child Plan ¨
Any assessments undertaken? / Webstar ¨
Early Help Assessment Form (EHAF) ¨
Other (please specify) …………………………………
……………………………………………………………
Ethnicity

Detail of parents (if known)

Parent/Carer Name/s / 1
2

Other main carers/adults living in the household where the child resides

Name / Relationship to child

Other children living in the household (if known)

Name / Relationship to child

Nature of concern Factual account of what happened, where and who was present using the child’s own words (if a disclosure was made)…Continue on Page 4 if you run out of space here.

Date and Time of the concern: / Location of event/disclosure:

Who has been notified of the referral?

Parent ¨
Carer ¨
Child ¨ / If the parent/carer has not been made aware of the referral, do not disclose the identity of the child until it has been confirmed by the Initial Contact Team that this concern meets the threshold for child protection.

Setting Details

Name of setting / Address
Telephone Number: / Postcode:

Details of staff member raising the concern

Name:
Position
Relationship to child:
Date: / Time:
Signature of Team Member

Details of Designated Lead Practitioner for safeguarding

Name
Position
Date: / Time:
Signature of Designated Lead Practitioner

Use this completed form to follow up your telephone referral in writing within 48 hours.

Agencies notified of concern and name of contact:

¨ Police______

¨ Shropshire Council Initial Contact Team______

¨ Disclosure and Barring Service______

¨ Local Authority Designated Officer______

¨ Ofsted______

Follow up (To be undertaken by the Designated Lead Practitioner).

If you have emailed the referral, print off a hard copy, sign and date it.

Confirmation of Receipt

Initial Contact Team

You will receive a feedback letter from a Social Worker informing you of the outcome of the referral to the Initial Contact Team. This letter should be securely stored with the referral documents.

Date Confirmation Received

Name of Initial Contact Team

professional confirming outcome

Outcome of Referral

If receipt of the referral is not received within 72 hours (3 working days) it is your responsibility to follow this up to obtain feedback from the Initial Contact Team.

Ofsted (Concerns that require referral to Ofsted such as significant events occurring on childcare premises or allegations concerning a member of staff)

Date Confirmation Received

Outcome of referral

Name of Ofsted

Professional confirming outcome

This referral together with any Confirmations of Receipt must be printed off, and signed by the Designated Lead Practitioner.

Date: ………………………………………………………………………..

Signature: ……………………………………………………………………

Once completed and signed, this referral must be stored securely following the setting’s procedure.


Nature of concern continued from page 1….

Designated Lead Practitioner Notes

Body Map 1

Body Map 2

Body Map 3

1