Child Protection Policy - Incident Report Form


Appendix 3: Incident Report Form

 

Date ........................ Location ................................

 

Name of child .................................... Age ................................

 

Parent's name ................................... Phone ................................

 

Home address ....................................................................................

 

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Explain the exact nature of the incident

 

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Did anyone else witness the incident. If so, who?

 

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Were any statutory authorities contacted, i.e. Police or Social Services? If so, please give details.

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Signed.....................................................................

Signature of Witness...................................................