The Glen Waverley Uniting Church PSALTER|
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| ||<tablestyle="width: 100%">Nature of alleged abuse:(Circle)||physical||emotional||sexual||neglect||witness domestic violence|| | ||<:99%(>Nature of alleged abuse:(Circle)||physical||emotional||sexual||neglect||witness domestic violence|| |
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| ||<tablestyle="width: 100%">Is this report due to: (circle)||a direct disclosure || reasonable grounds? || | ||<:99%(>Is this report due to: (circle)||a direct disclosure || reasonable grounds? || |
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| ||<tablestyle="width: 100%">If disclosure:<<BR>>.||Date:||Time:|| | ||<:99%(>If disclosure:<<BR>>.||Date:||Time:|| |
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| ||<tablestyle="width: 100%">Name: <<BR>>. ||<style="width: 10%">Age:||<style="width: 10%"> Male||<style="width: 10%">Female|| | ||<:70%(>Name: <<BR>>. ||<^10%">Age:||<style="width: 10%"> Male||<style="width: 10%">Female|| |
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: |
No closing quotation 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: |
No |
Date: |
Reported by whom?
Name of Government Service Call Centre Worker: |
Reference no: |
Have the police been notified? |
Yes |
No |
Date: |
Name of officer: |
Station: |
Advice given by police officer: