SafetyRiskSignificantHarmForm

3.2.7 Risk of significant harm form

To be completed by the person who hears a disclosure or wishes to report a child or young person at risk of harm. The complete form should be given only to the Safety Concerns Person and then kept in a locked filing cabinet. The information will be used for reporting to the Government Child Protection Department. Church Congregation name:

Safety Concerns Person:

DETAILS OF PERSON REPORTING ALLEGED ABUSE / RISK OF HARM:

Name of reporter:

Relationship to alleged victim:

Nature of alleged abuse:(Circle)

physical

emotional

sexual

neglect

witness domestic violence

Is this report due to: (circle)

a direct disclosure

reasonable grounds?

State immediate safety concerns:

If disclosure:
.

Date:

Time:

DETAILS OF ALLEGED ABUSED VICTIM

Name:
.

Age:

Male

Female

Address

Phone:
.

Parent/Guardian:

Names of Siblings:

Names of known support people to the child and family:

Have the parents/guardians of the victim been notified?

If yes, person(s) spoken to:
.

Date:

What were they told?

DETAILS OF ALLEGED PERPETRATOR OF THE ABUSE (IF KNOWN)

Name:
.

Age:

Male

Female

Address:

Phone:

Does the alleged perpetrator know about the report?

If yes, who spoke to him/her?
.

Date:

What was he/she told?

CHURCH’S RESPONSE TO ALLEGED ABUSE / RISK OF HARM

Child Protection Officer notified?
.

Yes:

Date:

Reported by whom?

Name of Government Service Call Centre Worker:
.

Reference no:

Have the police been notified?
.

Yes

Date:

Name of officer:
.

Station:

Advice given by police officer: