Safeguarding Children and Young People Incident Report

Safeguarding Children and Young People Incident Report

Young Reporters
The Child Safe Officer and the Victorian Area Representative is responsible for dealing with issues that make children and young people feel unsafe or when they are being hurt. You can contact us directly or get a trusted adult to contact us.

Ruihong Lu
Victoria Child Safe Officer
0423 623 111
childsafe@aikidomelbourne.org.au

Linda Godfrey Sensei
Victorian Area Representative
0418 391 674
godlinda@gmail.com

If you require assistance or would like to talk to a trained professional, please call
Kids Helpline on 1800 551 800 or
Lifeline on 131 114
We want you to know, all details entered below will be kept strictly confidential. Once we have reviewed your responses we will be in touch with you before we do anything else.
Please note: if you do not provide correct contact information and the details provided are insufficient to take your concern further this may result in the issue not being able to be progressed.
Full name of the person completing the form

First NameLast Name
Phone number

Area CodePhone Number
Email
example@example.com
Main dojo
Please type the name of the dojo you train most in.
AKA membership number (if you know it)
Whose concern are you reporting? You may be reporting your own concerns or the concerns of another person.
What is the first and last name of the person(s) this concern relates to?
Where did the incident, or incidents occur?
Has this concern been reported to the instructor/assistant instructor/trusted adults of your main dojo?
To whom has this concern been reported?
Was there more than one complaint or incident?
Date of the first complaint or incident (i.e. when did it first happen?)

DayMonthYear
2 digit day, 2 digit month, 4 digit year
If there was more than one, please provide further dates
Please provide as much information about the concern(s) as you can. I.e. what was noticed, what was done or said, by who?
Please verify that you are human
Your safety is our priority.

We will contact you shortly to gather more information.
Should be Empty: