Safe Church Concerns Form - SEECHANGE • Kingsway Community Church

Safe Church Concerns Form - SEECHANGE

Once completed, this form will be emailed to our Safe Church Team who will follow the Procedure for Responding to Child Protection Concerns.

This completed form, and attached documents must 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 of Person Completing this form:

First Name

Last Name

Your role:

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

Home Address

Home City

Home Postcode

Email Address

Mobile Number

Details of alleged victim (if applicable):

Full Name:

Birthday and/or Age:

Gender

Address:

Parent/guardian name and contact phone number:

Details of the alleged perpetrator:

Full Name:

Date of birth if known, otherwise approx. age:

Address:

Email:

Phone:

Position/Role at time of allegation (if any):

Is the person aware of the existence of the allegations?

Nature of the allegation:

Provide details of the allegations that were made known to you - what has been alleged, when/where it was alleged to have occurred, other relevant details. Please email any other supporting evidence to safechurch@kingsway.org.au

Name/s and contact details of any witnesses: (Please email any witness statements to safechurch@kingsway.org.au)

Who else is aware of this alleged abuse?

My declaration:

The information I have provided is the truest information and version of events as I recall them. I understand that this information will be held in strict confidence, but can be used in legal proceeedings should the need arise.

My Name:

Today's date:

FOR SAFE CHURCH TEAM USE ONLY:

Has the Mandatory Reporter Guide been completed?

Other government agencies or departments involved:

POLICE:

Time of Call:

Reference/Event Number:

Date of call:

Name of contact:

DCJ/CYPS:

Time of Call:

Reference/Event Number:

Date of call:

Name of contact:

OCG/Ombudsman:

Time of Call:

Reference/Event Number:

Date of call:

Name of contact:

Contact with church of Christ NSW?

Date and time:

Safe Church Team has provided feedback to the person bringing the concern about church response and any reports made:

Date and time:

Safe Church Team Member Name:

Date: