Risk of Significant Harm Form - Policy • Berwick Church of Christ Inc.

This Form must be completed by the person who hears a disclosure or wishes to report a child or young person at risk of significant harm.

Refer to the Child Safety Reporting Procedures before completing this Form.

Do not discuss this with anyone else, other than a Pastor or the Safety Contact Person.

DETAIL OF PERSON REPORTING ALLEGED ABUSE/RISK OF HARM

First Name *

Mobile Number *

Name of Your Leader/Pastor *

Your Relationship to the alleged Victim *

Last Name *

Email Address *

Your Role *

DETAILS OF VICTIM

First Name of Child/Young Person *

Gender *

Names of Parents/Guardians (if known) *

Tip: If not known - write Unknown.

Child's Mobile

Last Name of Child/Young Person *

Age *

Parent's Mobile

Child's Address

Names of known support people to the child and family

Have the Parents/Guardians of the Victim been notified? *

Yes

If Yes, provide the name of who you spoke to

What were the parents told? Give full details.

DETAILS OF ALLEGE ABUSE/RISK OF HARM

Date of Report/Incident *

Time: (24 hour clock) *

State immediate safety concerns: *

Is this report due to a direct disclosure or reasonable grounds (select which one) *

Disclosure

Reasonable Grounds

If Disclosure, include the date/time of the disclosure and provide a 'first person' report in this space. Record the child/young person's actual words. *

If Reasonable Grounds - describe why you have 'reasonable grounds' for this report. Include when, how, details of witnesses, details of injuries, child's behaviour, carer's attitude (if known).

DETAILS OF ALLEGED PERPETRATOR (IF KNOWN)

First Name of Perpetrator *

Gender *

Phone Number *

Tip: If unknown just type 0

Does the child know the person? *

Yes

Is the person involved in Ministry *

Yes

Does the alleged perpetrator know about the report? *

Yes

What was he/she told? Give full details.

Last Name of Perpetrator *

Age *

Tip: If not know give an estimate.

Address *

Tip: If unknown write Unknown.

If yes, please provide details of the relationship.

If yes, in what capacity?

If yes, who spoke to him/her?

DECLARATION & SIGNATURE

Electronic Signature

I agree that by checking this box, I am electronically signing this Report and declare that the above information is true and correct.

Date of signing this Report

PROCEDURES

If this concern is in relation to a person under the age of 18 years, please refer to the Child Safety Reporting Procedure.

If in doubt, ask a Pastor or the Safety Contact Person for help.

Call emergency services if there is immediate danger.
Listen to any concerns being raised.
- If you are under 18, ask a Pastor or the Safety Contact Person to assist you.
- Interact as follows:
  - Support the person and reassure them.
  - Emphasise that what occurred is not their fault.
  - Stop questioning the child and witnesses if the conduct described is like to constitute criminal conduct.
  - Consider whether expert assistance is needed to support a child to communicate their concern or disclosure (e.g. language interpreter).
  - Limit questioning, ask only open questions.
  - Don't make promises that cannot be kept.
  - Include that the information will remain confidential and tell the person who will be told and why.
  - Document the conversation using the person's exact words as far as possible.
Write up the concern straight away and any actions taken in response to the concern.
Report to the Police if you have a reasonable belief of child sexual abuse. (If you are 18 or over, you are personally obliged to report to police, if you have a reasonable belief that a person who is 18 or older has committed or attempted to commit a sexual offence against a child who is under 16.)
Respect everyone's privacy and do not discuss your concerns with anyone else. If you need support contact a Pastor or the Safety Contact Person.
On submitting this Form, it will be directly sent to the Safety Contact Person.

Safety Contact Person: Karen Fletcher
Mobile: 0438 886 337
Email: karenf@bcoc.com.au