Form for Reporting suspected or alleged Abuse/Bullying
Date: Time:
Name of Child: Age:
Home Address: Number:
Are you reporting your own concerns or passing on those of somebody else? Give details:
Brief Description of what has prompted these concerns (include dates, times etc of any specific incidents):
Any physical signs? Behavioural signs? Indirect signs?
Have you spoken to the child? If so what was said?
Have you spoken to the parent/s? If so what was said?
Has anybody been alleged to be the abuser/bully? If so give details:
Have you consulted anyone else? Give details:
Your name & role:
To whom reported and date of reporting:
Your signature.......................................... Today’s date...................................
Julie Laming.............................................. Today’s date...................................
(Mad4Dance Director)