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)