Bamboo - Safeguarding Form

Staff Name
Telephone number
Email address
Date Date / MM / DD YYYY
Time Time : HH MM AM/PM
Place
Learner Name
Learner ID
Date of Birth
Age
Gender

Gender Male Female
Has the learner got a disability:

Has the learner got a disability: Yes No
Adult at risk of harm:

Adult at risk of harm: Yes No
Address
Telephone Number
Email address
Is learner aware of the referral:

Is learner aware of the referral:
Yes No
Incident information:
This must be completed by the member of staff who received the disclosure. The DSO will then add additional information after speaking to the learner.
Learners feelings about what they would like to happen now they have disclosed:
Staff signature:
(Electronic signature)

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Learner signature (if appropriate): (Electronic signature)

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date received by Lead Designated Officer:
DSO:
In compliance with GDPR, you have the right to request a copy of the data entered on this form or to request its deletion at any time. The data is stored securely and can be accessed by emailing us. Please refer to our Privacy Policy for further information about how we process data. If you are happy to proceed, please confirm your consent below.