Child Safe Incident Report

Name of person making this incident report *

It is not possible to make an anonymous incident report using this form. All incident reports will be managed confidentially and stored securely.

Name of child or children affected *

Date of incident *

If unsure of the exact date, please choose an approximate date and make a note of this in the comments field below.

Type of incident

One or more selections may be made.

Place of incident *

E.g. In the church grounds, in the sanctuary, in the church hall, at a church BBQ

Names of anyone else involved

E.g. The name of the person causing physical injury or emotional discomfort, any witnesses

Description of the incident *

Detail of any injury to the child and of any medical attention received *

The child's description of the incident (if not witnessed by the person making this report)

Do you have further information that you wish to provide?

Yes - I consent to a Child Safety Contact Person contacting me to obtain this information

No

E.g. Photographs, medical reports, detailed statements

Has a Child Safety Contact Person already been made aware of the incident?

Yes

No

Unsure

E.g. By being called to the scene of the incident at the time it occurred

What would you like to see done in response to this incident?

Would you like to be contacted further about this incident report?

Yes

No

E.g. Should further information be required, or to be advised of the outcome of the report

To

From

Email

Subject

Phone

Comments