Incident & Disclosures Report Form

Date & Time of Report:

Reported By

First Name

Last Name

Position/Role:

Mobile Number

Email Address

Incident Details

Date of Incident:

Time of Incident:

Location of Incident:

Please list all individuals involved, including leaders & their roles:

Description of Incident:

Please provide a detailed account of what occurred, including what was said, done, and observed.

Immediate Action Taken:

Describe any immediate steps taken following the incident (e.g. separating individuals, providing first aid)

Witnesses:

List any witnesses to the incident, including their contact information if available:

Evidence:

Note any physical or digital evidence that may be relevant (e.g., emails, photographs, physical objects):

Confidentiality

Reminder: This report contains sensitive information and should be handled according to the organisation's confidentiality and privacy policies.

Signed by:

Office Use Only

Assigned to:

Follow Up Actions:

Outcome/Resolution:

Review Date: