Cause for Concern Report

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					                                      Cause for Concern Report
                                                                   PRIVATE AND CONFIDENTIAL
                                                                           URGENT FAO: BW / SP
                                       7 Southern Court, South Street, Reading, Berkshire RG1 4QS

Please refer your concerns immediately to your county’s Family Support Manager or
Child Protection Officer in their absence an Assistant Director. Ensure that the original of
this form is sent to 7 Southern Court on the day the concern is raised.

Family name & contact details:
Child’s name and address (if different from above):

Date of Incident:

Please outline the nature of your concern including when incident occurred, who was present,
exactly what was said by those involved, details of any injuries sustained. (Note the facts only, do
not guess or jump to conclusions)

If you have attached extra sheets make sure you sign and date each of them and write how many pages here:
Were there any independent witnesses to the event? If so what exactly did they see:

If the child’s parents / carers were not present have they been informed of the incident:

Please outline any action you have already taken:

Contact details of agencies informed of this incident:

Is the family is accessing support from anywhere else?

Name                                      Position / Job Support Worker

Nature of Support

Do they receive PACT Resettlement Support?                                  If Yes ref:

Has a family needs assessment been carried out to your knowledge?           If Yes when:

Has a previous CfC been completed to your knowledge?                        If Yes when:

Date: 02/09/2008

Your Name:                                                            Signature:

Seen by ……………………………………. Manager’s Name                               Signature:

                        Please send to 7 Southern Court immediately.
Issue 5: Jan 07

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