Date:

Time:

Details of child/young person

Name:

Male/Female:

M  /  F  (Please circle)

Address:

Date of birth:

School:

Teacher/Leader of group:

Details of person reporting concern

Name:

Tel. No:

Address:

Occupation/

Relationship to client:

Reporter wishes to remain anonymous:

Reporter discussed with Parents:

Parents aware of concern being reported to TUSLA?  

                                                                                                          Y / N   (Please circle)

Details of report

Details of i) type of concern ii) allegation or incident date  iii) who was present  iv) description of any observed injuries  v) parent’s view  vi) child’s view (if known)  

Relationships

Mother’s name:

Father’s name:

Address (if different to child):

Address (if different to child):

Tel No.

Tel. No.

Household composition

Name

Relationship

D.O.B.

Additional Information

E.g. school/occupation/other

Other personnel or agencies involved with this child

Name

Address

Social Worker

PHN

GP

Hospital

School

Gardai

Pre School/

Creche

Other (specify)

Details of person/s allegedly causing concern in relation to the child

Relationship to the child:

Age:

Gender:

                  M  /  F

Name:

Occupation:

Address:

Details of person completing the form

Name:

Occupation:

Signed:

Date:

Further notes/Actions taken: