SAFE CHURCH: Safe Churches Concerns Reporting • Menai Baptist Church

MBC - SAFE CHURCHES CONCERNS FORM

The completed form should be given to a member of your Safe Church Team who will follow the Procedure for Responding to Child Protection Concerns.

This documentation is to be kept in a locked filing cabinet and/or in secure electronic format for at least 45 years from the date of completion.

Please do not discuss the concern with anyone other than the Safe Church Team or your Ministry Team Leader.

If there is immediate danger please contact police immediately.

DETAILS ABOUT PERSON COMPLETING THIS FORM (either the victim, the person bringing a concern, or the safe church team)

Church Name: *

First Name: *

Last Name: *

Phone Number: *

Email Address: *

Address: *

Suburb: *

State: *

Post Code: *

Role: *

Relationship to the victim and/or the person allegedly causing harm: *

DETAILS OF ALLEGED VICTIM (if applicable)

First Name *

Last Name *

Date of Birth *

Gender *

Home Address *

Home Address Line 2 *

Home State *

Home Postcode *

Parent/Guardian Full Name: *

Contact Number: *

DETAILS OF THE PERSON AGAINST WHOM THE ALLEGATION HAS BEEN MADE (if applicable)

First Name: *

Last Name: *

Phone:

Email Address:

Address:

Suburb:

Sate:

Post Code

Date of birth if known otherwise approximate age: *

Position/title at time of allegation (if any): *

Is the person aware of the existence of the allegations? *

Yes

NATURE OF THE ALLEGATION

Provide details of the allegations that were made known to you - what has been alleged, when it was alleged to have occurred, other relevant details. *

Names and contact details of any witness/es: *

Are there written accounts from witnesses? If 'YES" please ensure they are handed in to the appropriate person. (written accounts should be received from each person who received a disclosure or observed a concern, however, do not start an investigation at this stage) *

Yes

Who else knows about the alleged abuse? *

Signature (of person bringing concern):

Date: