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Child Safety Incident Form
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Complainant's name (if other than the child) *
Complainant's contact details - phone & email address
 *
Complainant's role at club
 *
Child's name *
Child's age
Child's address
Team child connected with *
Date of Incident *
MM
/
DD
/
YYYY
Please summarise the reason to raise an incident or concern
 *
Complainant's reason for suspecting abuse
(e.g. observation, injury, disclosure)
 *
Type of alleged abuse (e.g. physical, sexual, emotional, inappropriate behaviour)
 *
Where alleged incident occurred (location)
 *
Who was involved in the incident
 *
Does the child identify as
Aboriginal or Torres Strait Islander?
 *
Does the incident involve discrimination based on any of these (tick those that are yes)
Name of person complained about
 *
Their role / status in the club
 *
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
 *
Interim action (if any) taken to ensure child’s safety and/or to support needs of person complained about
Were Police contacted?
Who:
When:
Advice provided:
 *
Was any Government agency contacted?
Who
When
Advice Provided
 *
Has the President and/or CSO been contacted?
Who
When
 *
Police and/or government agency investigation (if any)

Please report any findings
Internal / Club investigation (if any)

Please report any findings
Action taken *
Form Completed by
Name
Position *
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.
 *
Required
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