PCQ Child Safety Process Form • Presbyterian Church of Queensland

Purpose

This form is used for recording Child Safety related incidents including breaches of policy or procedure or code of conduct, disclosures of harm, suspicions of harm, or allegations of harm.

Child Sexual Abuse?

If this matter relates to Child Sexual Abuse, please be aware that the Queensland Criminal Code 229BC now requires that an adult disclose information on a child sexual offence to a police officer as soon as reasonably practicable. Please report directly to Police on 131 444.

The PCQ Risk Management Officer and/or Clerk of Assembly can provide support or assistance to help you report to the police prior to completing this form.

If the police provide a reference number, please enter that below.

Police Report Number

Summary of Breach, Allegation, Disclosure, or Suspicion of Harm

Describe the breach, allegation, disclosure or suspicion of harm in very brief terms within this section. This section is used as a Summary Identifier for your detailed report in the other section below. For more information refer to the Notification Procedure.

NB: If you are notifying a breach for transparency purposes please note this in the description below.

Description *

Location *

Category *

Date of Harm (if known)

Time of Harm (if known)

Person Harmed

If more than one person is the subject of harm then either enter the details of the main individual affected or enter the details of the individual with the alphabetically first surname then include other individuals' names and information in the Details field below. In complicated cases please submit a separate report for each individual.

If no person was harmed or more than one person was harmed please write today's date (e.g., "10/08/2022") in the Last Name field and the current time (e.g, "3:44PM") in the First Name field.

Last Name *

First Name *

Congregation

Date of Birth

Phone Number

Email Address

Details of Breach, Allegation, Disclosure or Suspicion of Harm

Provide clear details of the breach, allegation, disclosure or suspicion of harm within this section.

Details

Informant

Tip: The person who provided the details for this report

Suspect

Tip: The person suspected of the allegation

The Notifier is a contact for the matter whose details may be provided to authorities for followup.

This will generally be the Ministry Team Leader, Children’s Ministry Coordinator, or Minister.

Notifier Name *

Notifier's Position

Notifier Phone *

Action Taken

Describe any action taken in regard to this matter, including immediate action such as reporting to child safety services or police, and any follow-up action.