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Child Safety Incident Form
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* Indicates required question
Complainant's name (if other than the child)
*
Your answer
Complainant's contact details - phone & email address
*
Your answer
Complainant's role at club
*
Parent
Coach
Assistant Coach
Team Manager
Runner
Trainer
Committee member
Other:
Child's name
*
Your answer
Child's age
Your answer
Child's address
Your answer
Team child connected with
*
Your answer
Date of Incident
*
MM
/
DD
/
YYYY
Please
summarise the reason to raise an incident or concern
*
Your answer
Complainant's reason for suspecting abuse
(e.g. observation, injury, disclosure)
*
Your answer
Type of alleged abuse (e.g. physical, sexual, emotional, inappropriate behaviour)
*
Your answer
Where alleged incident occurred (location)
*
Your answer
Who was involved in the incident
*
Your answer
Does the child identify as
Aboriginal or Torres Strait Islander?
*
Yes, Aboriginal
Yes, Torres Strait
No
Unsure
Does the incident involve discrimination based on any of these (tick those that are yes)
Race
Gender
Sexual orientation
Religious or cultural beliefs
Other:
Name of person complained about
*
Your answer
Their role / status in the club
*
Parent
Coach
Assistant Coach
Team Manager
Runner
Trainer
Committee Member
Other:
Witnesses
(if more than 3 witnesses, attach details to this form) Name & contact details 1 / Name and contact details 2 / Name and contact details 3
*
Your answer
Interim action (if any) taken to ensure child’s safety and/or to support needs of person complained about
Your answer
Were Police contacted?
Who:
When:
Advice provided:
*
Your answer
Was any Government agency contacted?
Who
When
Advice Provided
*
Your answer
Has the President and/or CSO been contacted?
Who
When
*
Your answer
Police and/or government agency investigation (if any)
Please report any findings
Your answer
Internal / Club investigation (if any)
Please report any findings
Your answer
Action taken
*
Your answer
Form Completed by
Name
Position
*
Your answer
This record and any notes must be kept in a confidential and safe place and provided to the relevant authorities (police and government) should they require them.
*
Agreed
Required
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