Safe Church Concerns Form

Once completed, this form should be given to the ECC’s Safe Church Safeguarding Contact, who will follow the Procedure for Responding to Child Protection Concerns.

This completed form, and attached documents must be kept confidentially in secure electronic format for at least 45 years from the date of completion.

Please do not discuss the concern with anyone other than the ECC’s Safe Church Safeguarding Contact or your Ministry Team Leader.

If there is immediate danger please contact police immediately.

Church Name *

DETAILS ABOUT PERSON COMPLETING THIS FORM

(either the victim, the person bringing a concern, or the ECC’s Safe Church Safeguarding Contact.)

First Name *

Role

Relationship to the victim and/or the person allegedly causing harm *

Email Address *

Mobile Number *

Last Name *

Home Address

Home Address Line 2

Home City

Home State

Postcode

DETAILS OF ALLEGED VICTIM (if applicable)

Name

Date of Birth

Age

Gender

Address

Parent/ guardian name & contact phone number

DETAILS OF THE PERSON AGAINST WHOM THE ALLEGATION HAS BEEN MADE (if applicable)

Name

Date of Birth

Age

Address

Contact Number

Position/ Role at time of allegation (if any)

Is the person aware of the existence of the allegations?

Yes

NATURE OF THE ALLEGATION

Provide details of the allegations that were made known to you - what has been alleged, when/ where it as alleged to have occurred, other relevant details. *

Names and contact details of any witness/es

Tip: Witten accounts should be received from each person who received a disclosure or observed a concern). Please submit written accounts to ECC's Safe Church Safeguarding Contact.

Is there any written account from witnesses?

Yes

Who else is aware of the alleged abuse?

Signature (Full Name) *

Tip: Please type your full name above as your electronic signature, confirming that the information provided is true and that this form has been completed by you.