C3HB Helpline Contact Form - SC016 • C3 Henley Beach

C3HB Helpline Contact Form (Reporting and Responding to Concerns)

The form is initiated by the call from your church to the Safe Church Helpline 1800 070 511 + should be completed by the C3HB board, for record keeping. Where possible all fields to be completed. Details within this form will be passed to C3HB Senior Ministers.

Call Details: details of person who made the call

Date of Call

Time of Call

Role / Position

Caller First Name

Caller Last Name

Caller Contact Number

Location Detail

Location of occurance

Address

Team Lead at location

Tip: If applicable

Contact Details

Details of Concern: details of aggrieved person

Full Name

Age

Gender

Contact Details

Relevant details / issues to be aware of (e.g. cultural, disability, ethnicity)

Who does the person live with

Address

Is person aware of this report? (Yes/No)

Yes

Is parent or guardian aware of this report? (Yes/No)

Where is the person now

Is the person in a safe place? (Yes/No)

Are there any immediate medical issues? (Yes/No) + Detail

Details of Person Subject of the Allegation

Person subject of the allegation (C3HB church staff / volunteer / family member / congregation / community)

Full Name

Age

Contact Number

Gender

Address

Other relevant details (job, position, relationship with person)

The Concern

Type of Concern (Observed/suspected / Disclosure by person / Allegation by others)

Full Name of person making allegation

Contact Details

Date/s + Time/s of Incident/s

Location/s of Incidents

Details of Report

Please include: details of the concern/incident, what was alleged to have happened, exact words used, observations (mark as fact or opinion). Attach additional documentation if required.

Report Details

Completed by

Date

Pastoral / Legal / Organisational Considerations

Helpline Advice Provided

Pastoral Actions Implemented

Advice Provided (Pastoral)

Action Taken (Pastoral)

Government Child Protection Agency - Date of Call

Time of Call

Government Agency Incident Number

Advice / Action Taken (Govt Agency)

Police Contacted - Date of Call

Police Incident Number

Police Advice / Action Taken

Insurer Contacted - Date / Incident Number

Insurer Advice / Action Taken

Risk Management Actions

Actions Continued / Organisational Procedures

Declaration

Full Name

I confirm that the details above are accurate to my best knowledge

Tip: Please answer Yes or No.