Student Protection Incident Record
Date of incident: Location of incident:
Name and Grade of Student
Name and role of Reporting Staff Member
Details of the incident Note the reasons for recording the incident. Ensure the following factual information is provided – who, what, when and where. Include names of witnesses, if relevant, and immediate actions taken. Offer an explanation where relevant. Attach a body map or other information, if appropriate.
Signature of reporting staff member: Date:
Please pass this form to the Child Protection Officer
Responses to the incident including the names of anyone to whom the information was passed.
Outcomes:
Signature of Child Protection Officer Date: Signature of Deputy Director - Learning Date: Signature of Director Date: