Piseth

Your can use this reporting form or print it or photocopy it and fill them in or use the headings to help you as you write your own report.

The information covered by this form is confidential. It should only be sent to… The information will be held under safe and secure conditions.

You should attempt to provide as much of the information requested as possible. Leave blank those areas for which you have no knowledge. If you are raising a general concern about behavior that you have observed, then please make this clear. Use as many extra sheets of paper as you need to.

Part One - About You

Your name & address:

Your position:

Your relationship to the child:

Part Two - About the Child/ Children

Child’s name:

Is the child male or female?:

Child’s address:

Who does the child live with?:

Child’s date of birth/age:

Part Three - About Yor Concern

How did you come to have a concern?

• Was abuse observed or suspected?
• Was an allegation of abuse made?
• Did a child disclose abuse?

Date(s), time(s), and location(s) of any incident(s):

Nature of concern/ allegation:

Observations made by you (e.g. description of visible bruising, other injuries, child’s emotional state etc.): (N.B make a clear distinction between what is fact, opinion or hearsay.)

Exactly what the child said and what you said (N.B. Do not lead the child or young person - record actual details. Continue on a separate sheet if necessary):

Any other information:

For example is the child disabled/ does the child have communication problems/ learning difficulties?

Other children involved?:

External agencies contacted (if any) - date and time, name of person and any advice received:

Action taken:

Signed by:………………….

Date:………………………….