Safeguarding Incident Reporting Sheet

This form is to be completed if you have witnessed, been informed of or suspect that cases of abuse, exploitation or a breach of MSI’s Code of Conduct or Safeguarding Policies has occurred; or that there was or is an ongoing risk of danger to the safety and security of a client or staff member.

All protection concerns must be reported immediately to your Country Director (cd@mst.or.tz) , Regional Director (if in country) and Amanda Couper, Director of Safeguarding and Protection, (amanda.couper@msichoices.org).

This report should be completed and submitted immediately after a verbal incident report has been made; and in no case, more than 24 hours after the incident.

The report must be treated in strict confidence

Details of Concern / Suspicion / Incident:

Please fill out as many sections as possible with as much detail as you can.

Incident date:	Click here to enter text
Incident time:	Click here to enter text
Venue/location incident took place in:	Click here to enter text
Name of victim:	Click here to enter text
Age of victim: [particularly important for child safeguarding incidents]	Click here to enter text
Names of victim’s parent/ guardian [for child safeguarding incidents]	Click here to enter text

1) Describe what happened. Including: times; dates; names of persons involved; behaviours or signs observed; and any other relevant details you feel are applicable

Click here to enter text. Take as much space as you need

2) Describe in detail any conversations had with the victim

Click here to enter text. Take as much space as you need

3) Have you contacted anyone else about this concern?

☐ Yes

☐ No

4) If so, who have you contacted?

Click here to enter text.

Please sign, date and print your name and position to confirm that you have reviewed this form, verifying that the information provided is correct and truthful to the best of your knowledge.

Signed Date

Name:

Position:

Microsoft Office Signature Line...

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