Safe Church - Concerns Form • Mayfield Baptist Church

Safe Church - Concerns Form

Safe Church Concerns Form

Instructions

The completed form should be emailed to SafeChurch@Mayfieldbaptist.com and will be responded to by a member of the team who will follow the Procedure for Responding to Child Protection Concerns.

This documentation is to be kept in a locked filing cabinet and/or in secure electronic format for at least 45 years (preferably 100 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 or Pastor.

If there is immediate danger please contact police immediately.

DETAILS ABOUT PERSON COMPLETING THIS FORM

Please state your reason for completing this form *

First Name *

Relationship to the subject of the concern *

Role in relation to this statement *

Last Name *

Relationship to the person who is alleged to have caused harm

Mobile Number *

Home Address *

Email Address *

Suburb & Postcode *

Details about person who is the subject of the concern

Please provide as much information as is known

Subject: First Name *

Subject: Mobile Number

Subject: Residential Address

Subject: Date of Birth

Subject: Sex

Subject: Surname *

Subject: Email address

Subject: Suburb & Postcode

Subject: Age or approx age

If person who is subject of concern is 17yrs or younger, please fill in parent/guardian details

Parent/Guardian: First Name

Parent / Guardian: Mobile Number

Parent / Guardian: Home Address

Parent / Guardian: Surname

Parent / Guardian: Email

Parent / Guardian: Suburb & Postcode

Details about person against whom the allegation has been made

Please complete as much as is known

Person alleged to cause harm: First Name

Person alleged to cause harm: Mobile

Person alleged to cause harm: Home Address

Person alleged to cause harm: Date of Birth

Person alleged to cause harm: Position / Role at time of allegation

Person alleged to cause harm: Surname

Person alleged to cause harm: Email

Person alleged to cause harm: Suburb & Postcode

Person alleged to cause harm: Age or approx age

Is the person alleged to cause harm, aware of allegations?

Nature Of The Allegation

Provide details of the allegations that were made known to you. Use direct quotes, known as a word-for-word, verbatim report

What has been alleged?

When was it alleged to have occurred?

Where was it alleged to have occurred?

Other relevant details as told to you

Please do not ask Yes/No Questions or probe for details.

You may say 'What happened next?' if relevant

Offer to a child: I will need to let some people in charge know who can help with this

Offer to an adult: we have a Safe Church Team whose job it is to initiate the correct processes

You may offer that the person reporting has done the right thing.

DO NOT offer to 'make it stop or go away'

Nature of the Allegation

Other witnesses: Names and Phone Numbers (& Email if possible)

Tip: If there are witnesses please provide a way to contact them

Please request any witnesses to write their own account and send it to SafeChurch@mayfieldbaptist.com

Alternatively provide them with a link to this form, to complete their own account.

Who else knows about the alleged abuse?

For complete clarity: Please complete the Name of Person Reporting the CONCERN and submitting this form

Date Form submitted