CCC Complaints and Allegations Record Form

This form should be used to record a suspicion, allegation or disclosure of child abuse, or a complaint of unacceptable behaviour.

Please provide as much information as you are able to. If you are unsure of a response, please state that in the box.

For any questions or enquiries, please contact Council on (02) 9911 6555.

Your Name *

Your Position *

Community memberCity of Canada Bay Council Employee

Name of the child or young person involved *

Name of the person making complaint *

Name of person who the complaint was made against *

Details of Complaint

Nature of the complaint *Include the time, date, location, what happened and who was involved (this can include observations of the child's behaviour)

Detail any injuries and if the child received medical attention *

Accurately record what the child said when describing what happened - use their exact words - or record why you suspect abuse due to an indirect disclosure, such as a drawing or observed behaviour *In the case of an allegation of abuse, formal investigations and interviews will be carried our by the Department of Communities and Justice (DCJ) and/or NSW Police. You must record what the child has said, but unless it is your role to investigate, you should not interview the child.

Details of anyone who saw what happened *

Does this complaint indicate the possibility of child abuse, such as physical abuse, psychological or emotional abuse, sexual abuse or neglect? *

YesNoUnsure

Have you made a report to any of the following?

NSW PoliceDepartment of Communities and Justice (via ChildStory)Department of Communities and Justice (via Child Protection Helpline 132 111)Office of the Children's Guardian (OCG) Reportable Conduct Directorate Internal reporting obligationsOther

Select all that apply.

Name the relevant department or person *

Name the other agency/reporting mechanism *

Name the people spoken to in relation to the matter *Describe who was spoken to and why they were spoken to about the matter - include Police Officers, DCJ staff, OCG staff and anyone else you spoke to.

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