Child Safety Incident Report

Date of Incident *

MM

DD

YYYY

Time of Incident *

Hour

Minute

Second

AM PM

Name(s) of child/children involved: *

First Name

Last Name

Name(s) of staff/volunteer involved: *

First Name

Last Name

Does the child identify with any of the following: *

(Mark with an 'X' or 'Tick' as applicable) - Why is this information important? The Royal Commission advises that some children are more vulnerable to abuse, based on various factors including age, gender, ethnicity, disability, and prior abuse or neglect. This information identifies if any additional assistance may be required through the reporting and support process

Aboriginal descent

Torres Strait Islander descent

Culturally & Linguistically Diverse background

Disability

Please categorise the incident: *

Physical abuse

Sexual abuse

Serious emotional or psychological abuse

Serious neglect

Racial, cultural or religious abuse

Has the incident been reported to any of the following? *

Please select one or more of the following

Child Protection

Police

Child Safe Officer/Delegate

Another third party (i.e. A partner of African Youth Initiative, an organisation/social group that is auspiced by African Youth Initiative, or Commission for Children and Young People)

None of the above

Does the incident reporter wish to remain anonymous? *

Yes

No