Abundant Life Centre Busselton
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FORMS
CHILD ABUSE REPORT FORM
If you believe a child is at immediate risk of abuse - phone 000
*
Indicates required field
1. DATE OF INCIDENT (dd/mm/yyyy)
*
TIME OF INCIDENT
*
2. LOCATION of INCIDENT:
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NAME OF PERSON LODGING REPORT (you)
*
3. NAME(s) OF CHILD / CHILDREN INVOLVED
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If there is more than one person injured, a separate incident / injury form will be required.
NAME(s) OF PERSON(s) SUSPECTED:
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4. PLEASE CATEGORISE THE INCIDENT:
*
- please select -
Neglect
Physical Abuse
Emotional / Psychological Abuse
Sexual Abuse
5. PLEASE DESCRIBE THE INCIDENT (what you observed, heard or have been made aware of).
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How did you become aware of this information? Is there any other information you feel to include?
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7. WITNESSES (Did anyone else directly witness the incident?)
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- please select -
Yes
No
Name and phone number of witness(s) (if applicable)
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8. DATE OF REPORT (today) (dd/mm/yyyy)
*
Thankyou for taking the time to complete this report. It will be forwarded to ALC admin once submitted.
Submit