Northern Rivers Children’s Services Ltd.

Suspected Risk of Significant Harm Report Form

This form is intended for use by Mandatory Reporters. It is designed to assist in collecting information that may be required when making a report. Once a report is made this form may be either destroyed, or kept by the reporter in a personal file. The reporter is required to alert FDC/IHC that a report has been made, but is not required to give details of the report. Educators and staff are however encouraged to discuss the incidents / concerns leading to the report with the NRFDC CEO, Directors or Coordinators.

Prior to reporting refer to our Policy and the Mandatory Guide: see attached fact sheet.

Family details of child or young person about whom the report is being made:

Child/ren’s name, age and DOB:

Siblings: ______

Address of the child

Child’s school/other childcare (if applicable)

Parent/s and/or guardian name

Address (if different from child)

Phone/contact details

Other relevant family information (e.g. how long separated/ divorced, custody info, if parent in refuge, which one etc.______

Caller/staff details will be asked for by the helpline. This information is protected

Caller concerns/reason for call and details of the incident

i.e. what has prompted the call? Is there concern for a child or young person’s immediate safety?

Reasons for believing the child has been harmed, or is atsignificant risk of harm (read the Mandatory Reporting Guide, onlineor a hard copy is available at the FDC/IHC Coordination Unit)

Consider:Why do you think the child is at Risk ofSignificant Harm and what has led you to that conclusion?

Date and time of any particular incident and whether police were called.

Medical treatment required? Who, what and given by whom?

Were children, witness to or harmed by, a violent event?

What was the impact of the incident on the child/young person?

Have there been previous reports made, or unreported concerns/incidents?

Network of support around the child/young person.

Cultural and family issues/ Interpreter/support requirement: whether a language or sign interpreter may be required, whether a support is required for a person with a disability or an Aboriginal agency is involved.

Family relationships/alcohol or other drug issues/parenting or domestic violence issues (including AVO’s if known)/mental health issues.

Other agencies involved, or other information/contact persons

Before making a report, read the NSW DOCS Mandatory Reporters Guidelines, Report Checklist and Scheme Policy Provided by Northern Rivers Children’s Services Inc.

Copyright Northern Rivers Children’s Services Ltd.: Source Reference: NSW Family & Community Services, Keep Them Safe and Child Wellbeing & Child Protection NSW Interagency Guidelines Publications 27/10/2016, Accessed 24/10/2017