Child Safety Concern Report Form

Use this form to document any child safety concern. If in any doubt about whether something is a child safety concern, always document and report it.

IF SOMEONE IS IN IMMEDIATE DANGER, CALL 000, AND THEN COMPLETE THIS FORM

Child Safety Concern Report Form

Use this form to document any child safety concerns.

If in any doubt about whether something is a child safety concern, always document and report it.

Please provide all relevant and known details as accurately as able.

1. Details of Affected Child:
Please provide known details of the affected child
1

(DD/MM/YYYY)

e.g. interpreter or augmentative/alternative communication device?
Person reporting the concern (if not Affected Child)
1

DD/MM/YYYY

Contact Details of Person Reporting the Concern:

Select all preferred
Nature of the Concern
If the concern was disclosed by the affected child or another person, as far as possible record the nature of the concern using their own words.
1
Risk Management
Provide details of identified risks and the actions taken to manage them.
1
Person Completing this Form
This person may be the same person reporting the concern.
1