Child Abuse Incident Reporting Form
This form can be used to report details of a Child Abuse Incident or Allegation
In line with our Child Safety & Wellbeing Policy, Learn to Swim Victoria provides the ability for staff, parents, and children to report suspected Child Abuse. All complaints and feedback in relation to Child Safety & Wellbeing will be handled in accordance with our Child Safety & Complaint Feedback Policy (https://learntoswimvic.com.au/child-safety/).
Report Information
Childs Name
*
First Name
Last Name
Date of Incident
*
-
Month
-
Day
Year
Date
Where did the Incident Occur?
*
Name Person Making the Report
*
Relationship to Child
*
Type of Incident (Select all that apply)
A complaint
A Breach of Duty of Care
Suspicion / Allegation of Child Abuse
Suspicion of harm to a client
Other
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Details of the Child
Complete as much as possible
Childs Name
First Name
Last Name
Date of Birth
Gender
Male
Female
Other
Known Medical or Communication Requirements
Parent / Guardian Name
Parent / Guardian Contact Number
Parent / Guardian Contact Email
Parent / Guardian Address
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Details of the Perpetrator(s)
Complete as much as possible
Name
First Name
Last Name
Connection with Child
Any other Relevant Factors
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Other People
Please provide details of any other people involved (i.e witnesses)
Type a question
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Details of the Incident
Please Describe What Happened (Including the perpetrator's behaviour, sighted injury, indicators of abuse, conversations with the child etc.)
Please Provide any further details which may support this complaint
Submit
Should be Empty: