Early Childhood Education and Care

Recording Form for Disclosures, Observations of Child Abuse and Actions

A mandatory report of sexual abuse must be completed by the reporter. Reports of all other forms of abuse may be completed by the reporter or the principal on
their behalf.

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1. REPORTER’S DETAILS (*fields must be completed)

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*Reporter’s Name Rita Profession Childcare Educator

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*Workplace Address Sparkling Stars Childcare Centre
or Other Address for

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response to report

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*Contact Phone No. XXXXXXXXXXX Fax no. Email add

Is this a written report Date of Report:

following a telephone X No If yes, write the MRS receipt number

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Yes
report? Time of Report:

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2. DETAILS ABOUT THE CHILD (If more than one child is involved, record their names in Section 5)

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*Child’s first name (or
description of child if name Erica *Child’s last name Smith
unknown)
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24th Febuary 2009
Or estimated age of
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Date of birth
the child
Male Female (X) Disability
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CaLD (Cultural and Linguistic

Cultural Identity Australian
Diversity, if known)
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 Language spoken at home
Interpreter required No (x) Yes à
English

Address 35 Kinalley Cres, Cascade Peaks

Suburb/Town/Location Cascade Peaks Postcode 3809

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Home Phone 0000 000 Mobile No. 000 0o00

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Current residence of the
child/young person
35 Kinalley Cres, Cascade Peaks

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School/pre-school
attended or child care

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service or arrangement
etc. (Family day care/nanny,

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etc., if known)

3. NAME OF PARENT/CARER/OTHERS PROVIDING CARE (if known)

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First Name Erson Last Name Smith

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Address (if different from above)

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Phone (if different from above)
Relationship to the child/young co rc Mother
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person (if known)
Significant others close to the
child and/or the family (e.g.,
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Grandparents/aunts/uncles, etc.)

4. PERSON BELIEVED RESPONSIBLE FOR ALLEGED ABUSE OR HARM (if known)

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First Name Roger Last Name James

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 Address 35 Kinalley Cres, Cascade Peaks Suburb/Town/Location
Phone 0000 0000 Mobile No.
Relationship to child/young person (if known) Father
Do you know if this person is known to Police? Do you know if this person is known to DCP?

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X No Yes X No Yes

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5. DETAILED REPORT

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Provide details of the grounds for your belief that a child has been the subject of physical, emotional/psychological abuse or neglect.

Under the relevant section of the state/territory Children Protection Legislation you must provide details of the grounds for your belief that the above named

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child has been the subject of sexual abuse or is the subject of ongoing sexual abuse.

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You may also provide information that you think is of concern and has informed your belief that child abuse is alleged to have occurred or is likely to occur.
Attach additional page if required.

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These holidays, you've noticed that Erica isn't her usual blistering self. She wore the same dirty clothes to take
care of her several times the other day, and one day you hear her asking a friend for some food at lunch.

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One day, when I joined the team swimming, Erica didn't bring her bathing suit. When you ask her a question,

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she answers, "my father says I'm too fat to swim."
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When Erica and her father arrived at the center the next morning, her eyes were red and puffy. You think she
looks like she's crying.
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That morning, you noticed that Erica might have hurt her upper arm playing in the home corner.
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Later that day, when you were preparing afternoon tea, Erica approached you shyly and spoke very quietly. You
bend over to hear her better, she says: "my father hurt me."
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 6. CONCERN FOR SAFETY OF CHILD
Do you have a concern for the immediate
Yes (x) No X Unsure
safety of the child concerned?

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7. SIGNATURE

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Reporter’s Signature Rita Principal’s Signature (optional)

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8. WHERE TO LODGE A REPORT OF ABUSE

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Non-mandatory report Mandatory report

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Mandatory reports are lodged with the Mandatory Reporting Service
(MRS) as follows:
Email: mrs@dcp.state.gov.au
The principal must forward all reports of non-sexual abuse to the local Fax: 1800 *** ***

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Child Protection office. Post: Mandatory Reporting Service
PO Box ****

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My State Postcode

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Note: These forms are for information purposes only and have been adapted from templates initially developed by Department of Education in Western
Australia

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