## page was renamed from 3.2.7 Risk of Significant Harm Form
## page was renamed from 3.2.7 Risk of significant harm form
#acl NeilSkilton:read,write All:read
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== 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:
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Safety Concerns Person: 
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=== DETAILS OF PERSON REPORTING ALLEGED ABUSE / RISK OF HARM: ===
Name of reporter: 
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Relationship to alleged victim:
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||<:99%(>Nature of alleged abuse:(Circle)||physical||emotional||sexual||neglect||witness domestic violence||

||<:99%(>Is this report due to:  (circle)||a direct disclosure || reasonable grounds? ||
State immediate safety concerns: 
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||<:70%(>If disclosure:<<BR>>.||<^:20%>Date:||<^:20%>Time:||

=== DETAILS OF ALLEGED ABUSED VICTIM ===
||<:70%(>Name: <<BR>>. ||<^:10%>Age:||<:10%> Male||<:10%>Female||
Address
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||<tablestyle="width: 100%">Phone: <<BR>>. ||<^>Parent/Guardian: ||
Names of Siblings:
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Names of known support people to the child and family:
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Have the parents/guardians of the victim been notified?	
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||<tablestyle="width: 100%">If yes, person(s) spoken to:<<BR>>.||<^>Date:||
What were they told?
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=== DETAILS OF ALLEGED PERPETRATOR OF THE ABUSE (IF KNOWN) ===
||<:100%>Name: <<BR>>. ||<^:20%>Age:||<style="width: 10%"> Male||<style="width: 10%">Female||
Address:
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Phone: <<BR>>
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Does the alleged perpetrator know about the report?
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||<tablestyle="width: 100%">If yes, who spoke to him/her?<<BR>>. ||<style="width: 20%">Date: ||
What was he/she told?
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=== CHURCH’S RESPONSE TO ALLEGED ABUSE / RISK OF HARM ===
||<tablestyle="width: 100%">Child Protection Officer notified?  <<BR>>. ||<style="width: 10%">Yes:||<style="width: 10%"> No||<style="width: 20%">Date:||
Reported by whom? 
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||<tablestyle="width: 100%">Name of Government Service Call Centre Worker: <<BR>>. ||<style="width: 20%">Reference no: ||

||<tablestyle="width: 100%">Have the police been notified? <<BR>>. ||<style="width: 10%"> Yes||<style="width: 10%"> No ||<style="width: 20%"> Date:||

||<tablestyle="width: 100%">Name of officer:<<BR>>. ||<style="width: 50%">Station: ||

Advice given by police officer:
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