Child Protection – Disclosure of Harm

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Child Protection – Disclosure of Harm

A disclosure of harm occurs when someone, including a child, tells you about harm that has happened, is happening, or is likely to happen to a child. Disclosures of harm may start with:

• I think I saw…
• Somebody told me that…
• Just think you should know…
• I‘m not sure what I want you to do, but…

 

Child’s name      __________________________________________________________________

What is the name of the person who made the disclosure? _________________________________

Are they related to the child? Yes No

If yes, what is the relationship? ________________________________________________________

What did the person disclose? Try to use the exact words they used. Use “I said” “they said” statements, include any questions you asked and comments you made

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________

What date did the person make the disclosure?  ________________   What time?_______AM/PM

Where did the disclosure occur? _______________________________________________________

Was anyone else present during the disclosure? Yes No

If yes what is/are their name, role and employer?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Have you followed the procedure in the Child Protection Policy for making a report? Yes No

Nominated Supervisor advised? Yes No

Nominated Supervisor comments if any

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Report made to Police? Yes No

Only applies if child in immediate danger

 or criminal offence

 

If yes record date, time, reference and advice

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Report made to Child Protection? Yes No

If yes record date, time, reference and advice or attach acknowledgement from child protection.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Referred to Support Services with family’s consent? Yes No

If yes record date, time, reference and advice

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Report made to Regulatory Authority? Yes No

Any physical or sexual abuse that occurred at the

 service must be reported

 

If yes attach acknowledgement

Report made to other relevant organisations? YesNo

See Child Protection Policy

If yes record date, time, reference and advice

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe any other actions you have taken

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

___________________________	___________________________	_____________/_____________
Staff Member Signature	Staff Member Name (Please print)	Date/Time
___________________________	___________________________	_____________/_____________
Witness Signature (if any)	Witness Name (if any) (Please print)	Date/Time
___________________________	___________________________	_____________/_____________
Nominated Supervisor	Nominated Supervisor (Please print)	Date/Time

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