Safeguarding Children & Vulnerable People Handbook

Confidential

SUSPECTED CHILD or VULNERABLE PERSONS ABUSE REPORT FORM

This form it be used when reporting ANY suspected abuse of a child or vulnerable person.This form is to record information only, no investigation is permitted by the reporter. In accordance with St John Ambulance Australia SA Inc’s Child Protection & Mandatory Notification policy and procedure, all incidences of child abuse or suspected child abuse are to be reported directly to Families SA by contacting CARL on 13 14 78. Suspected abuse of a vulnerable adult is to be reported directly to the Child and Vulnerable Persons Officer and to SAPOL in the case of an emergency. This form is to be filled out by the person making the report and forwarded to the CEO or Commissioner and Child and Vulnerable Persons Officer immediately. Please see the reporting procedures for suspected abuse as outlined in the Safeguarding Children and Vulnerable Persons handbook.

Alleged victim details: Mr Mrs Miss Ms

For children: Have you notified Families SA? Yes No Date of report: Have you notified SA Police? Yes No Date of report:

Other

Full name

Address/s

Have you notified the parent/s or guardian/s? Yes No Date of contact:

Have you notified the Child & Vulnerable Persons’ Protection Officer? Yes No Date of report:

Contact numbers

Ethnicity

DOB

/

/

Female

Male

For adults: Have you notified the Child & Vulnerable Persons’ Protection Officer? Yes No Date of report:

Your details: Mr Mrs

Miss

Ms

Other

Full name

Have you notified SA Police? Yes No Date of report: Have you notified the family? Yes No Date of contact:

Address/s

Contact numbers

The report is based on: The disclosure made by a child/ren or young person/s or vulnerable adult. Yes No

Title/Position

Relationship to victim

Name of alleged perpetrator/s: Mr Mrs Miss Ms Other

An allegation been made to me. Yes No

Full name

My own concerns or observations. Yes No

Address/s

Disclosure/admission from family member. Yes No

Contact numbers

Relationship to victim

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Member Handbook July 2016 St John Ambulance SA Inc