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iSEE CHURCH Safer Churches Report Form
Thank you for completing this Report Form.  Please keep information as accurate as possible. This form is sent directly to the iSEE Safer Churches Committee. The committee will consider the information provided and contact you if necessary.
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Date of disclosure *
MM
/
DD
/
YYYY
Time of disclosure
Time
:
Your Name (the person completing this form)
Phone Number
Role/Title/Relationship to iSEE CHURCH
Location
Clear selection
Todays Date
MM
/
DD
/
YYYY
Victims Details 
First Name
Last Name
Date of Birth (DOB)
MM
/
DD
/
YYYY
Age or Approximate age of victim if date of birth unknown
Address (if known)
Contact No. 
Parent/Carer/Guardian Details
Name
Address (if known)
Contact No.
Is She/He aware of this disclosure?
Clear selection
Does this disclosure involve a family member?
Clear selection
Alleged Perpetrator Details (if known)
Complete as much information that you know
Name
Address (if known)
Contact No.
Does the victim know this person?
Clear selection
If yes, provide the details of the relationship
Is this person involved in iSEE CHURCH?
Clear selection
If yes, in what capacity?
Disclosure details - Tip: Please provide details of the concern, allegation or complaint. Include dates/times and location of incident(s) as disclosed (if known).

It is important to provide as much information as possible, basing your information on facts and observations, without making assumptions or jumping to conclusions or making “value” judgments. 

If a disclosure has been made, a verbatim (word for word) account must be written of the disclosure to the best of the reporter’s ability, as soon after the disclosure as is practical.
Disclosure details 
Does the victim know this disclosure is being documented?
Clear selection
Does this disclosure refer to staff member or volunteer misconduct?
Clear selection

This information is to be kept strictly confidential and not to be used for any other reason except for the purpose of reporting the alleged abuse or harm. 

The provision of information to the Statutory Authorities for the protection of a child or young person is not a breach of confidentiality. 

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