Bamboo - Safeguarding Form
Bamboo - Safeguarding Form
Staff Name
Telephone number
Email address
Date
Date
/
MM
/
DD
YYYY
Time
Time
:
HH
MM
AM
PM
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: