Confidential Child Protection Reporting Form
MCS staff members and volunteers are responsible to report any suspicion, concern, or disclosure of any child being at risk of harm, whether in school or outside of school, within 24 hours to the Child Protection Officer (CPO) using this form. This form is to be completed with only the information that is known at the time the disclosure is received or harm observed.

Students, parents, community members or visitors are welcome to use this reporting form.

This form may also be used to disclose any historical allegations.

PLEASE ANSWER THESE QUESTIONS TO THE BEST OF YOUR ABILITY. IF YOU DO NOT KNOW THE ANSWER LEAVE BLANK.

This report will be kept confidential

Email address *
Your name
Your answer
Your position or grade
Your answer
Your contact details (email/phone number)
Your answer
Name of person harmed
Your answer
Gender/Age/Grade
Your answer
Parents' names of person harmed
Your answer
Parents' contact details of person harmed
Your answer
Alleged persons causing harm (Name/ Grade/ Age/ Relationship to person harmed)
Your answer
How this information was disclosed, observed or suspected
Your answer
Details of what was disclosed, observed or suspected. Please include dates, frequency, location and what happened as accurately as you can. If applicable please quote as much of the words spoken as possible.
Your answer
Are there any immediate concerns regarding the accessibility of the person(s) who has done the harm to the person who has been harmed?
Your answer
Is there any other information you would like to give?
Your answer
Thank you. The Child Protection Officer will confirm that this report has been received. If there any other concerns please write to childsafety@mtview.id
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Mountainview Christian School. Report Abuse - Terms of Service