Child Safe Reporting Form | DerDieDas Inc.

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DerDieDas Child Safe Incident Report Form

Please use this form to report if you form a reasonable belief that a child needs protection or when there is a disclosure of abuse or harm.

How to complete this Child Safe Incident Report Form

Details of Person Reporting

First Name

Role

Last Name

Phone

Would you like to stay anonymous to the DerDieDas Mgmt. Committee? *

Yes

Details of any person(s) who witnessed or is aware of the incident

First Name

Role

Last Name

Is the person aware of you making the report? *

Yes

First Name

Role

Last Name

Is the person aware of you making the report? *

Yes

First Name

Role

Last Name

Is the person aware of you making the report? *

Yes

Details of the person implicated in the reportable conduct

First Name

Role

Last Name

Is the person engaged by DerDieDas Inc.? *

Yes

Unsure

Details of the child/ children involved (if known)

First Name

Child's address

Date of birth

Last Name

Gender

Carer's / Carers' Name(s)

First Name

Child's address

Date of birth

Last Name

Gender

Carer's / Carers' Name(s)

First Name

Child's address

Date of birth

Last Name

Gender

Carer's / Carers' Name(s)

Incident Details

Please categorise the incident (more than one can be selected if appropriate)

Physical violence against, with or in the presence of, a child

Sexual offence against, with or in the presence of, a child

Sexual misconduct against, with or in the presence of, a child

Emotional or psychological abuse - behaviour likely to cause significant emotional and/ or psychological harm

Significant neglect - not meeting obligations to keep a child safe and well

Grooming - concerns of predatory conduct to prepare a child for sexual activity

Date of incident

Time the incident occurred

Location of the incident

Did it happen before, during or after a DerDieDas program?

What happened?

Has the incident been reported?

No report made other than through this form

Child Protection

Police

Other

Time of report

Submit

Thank you, we have received your report.

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