Harlem United Methodist Church
Monday, September 25, 2017

Safe Sanctuary Incident Report Forms

Incident Report Form for Harlem UMC (Appendix A)

Please print all information

Date of Incident: ________________________ Time of Incident: _______________________

Name of child/student injured: ___________________________________ Age: ____________

Address of child/student: ________________________________________________________

Location of incident: ___________________________________________________________

Parent or guardian: _____________________________________________________________

Name of person(s) who witnessed the incident:

        Name: ________________________________ Phone: ________________________

        Name: ________________________________ Phone: ________________________

        Name: ________________________________ Phone: ________________________

Describe incident: _____________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

_________________________________________________       ________________________

                             Signature                                                                        Date Signed

 

 

Report of Suspected/Alleged Incident of Child Abuse  Harlem United Methodist Church (Appendix B)

1. Name of worker (paid or volunteer) observing or receiving disclosure of child abuse:
_________________________________________________________________________________________

2. Victim’s name: ____________________________________________________________________________

3. Victim’s age / date of birth: __________________________________________________________________

4. Date/Place of initial conversation with/report from victim: __________________________________________

_________________________________________________________________________________________

5. Victim’s Statement (give your detailed summary here) :

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

6. Name of person accused of abuse: _____________________________________________________________

Relationship of accused to victim (paid staff, volunteer, family member, other, etc.):

_________________________________________________________________________________________

7. Reported to Senior Pastor : ___________________________________________________________________

Date/Time: _______________________________________________________________________________

Summary: ________________________________________________________________________________

_________________________________________________________________________________________

8. Call to victims’ parent/guardian: _______________________________________________________________

Date/Time: _______________________________________________________________________________

Spoke with: _______________________________________________________________________________

Summary: ________________________________________________________________________________

_________________________________________________________________________________________

9. Call to local children and family service agency: __________________________________________________

Date/Time: _______________________________________________________________________________

Spoke with: _______________________________________________________________________________

Summary: ________________________________________________________________________________

_________________________________________________________________________________________

10. Call to local law enforcement agency: _______________________________________________________

Date/Time: _______________________________________________________________________________

Spoke with: _______________________________________________________________________________

Summary: ________________________________________________________________________________

_________________________________________________________________________________________

11. Other contacts: ___________________________________________________________________________

Name: ___________________________________________________________________________________

Date/Time: _______________________________________________________________________________

Spoke with: _______________________________________________________________________________

Summary: ________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________          _________________________

                                   Signature                                                                               Date Signed

 

 

 

Appendix C: Suspected Child Abuse Report Form

1.      Student Reported__________________________________________________

2.      Date Reported_____________________________________________________

3.      Grade _________

4.      Date of Birth ____________________________

5.      Name(s) of Parent(s)/Caretaker(s)_____________________________________

6.      Student’s Address__________________________________________________

________________________________________________________________

7.      Home or Cell Phone _____________________

8.      Work/Emergency Phone(s)________________

9.      Siblings (List Grade, Age, and School)__________________________________

________________________________________________________________

10.  Nature of Report: ____ Physical Abuse ____ Sexual Abuse ____ Neglect ____ Other__________________________________________________________

11.  First Employee to Receive This Information_____________________________

12.  Name and Numbers of Other Person(s) Who Could Provide Information About Incident Reported:__________________________________________________

________________________________________________________________

13.  Detailed Description of Allegations Including Child’s Statement_______________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

1.      When Did This Incident Occur?_______________________________________

2.      Name(s) of Alleged Maltreater(s)______________________________________

3.      Does Alleged Maltreater Live in the Home with the Child?___________________

4.      Does the Child Have Any Marks/Bruises? ___ Yes ___ No

If yes, where are the marks/bruises located?__________________________

If marks/bruises, were photographs taken?___ Yes___ No

 

Name and Position of Person Making Report

_____________________________________________________________________

(Please Print)

Signature of Person Making Report_________________________________________