Child Safety Form

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Report of Possible
Harassment or Abuse

School staff, volunteers, and parents are responsible to report indicators, disclosures, or concerns regarding possible harassment or abuse. These reports should be given to a school administrator or member of the Child Safety Team within 24 hours. The report may be submitted using this form or by sending an email to hotline@dalat.org.

Please fill this form out with only the information that is known without researching or investigating the situation. When you make a report, you are not making an accusation, you are simply requesting for a professional service to be done.

Your Name: *

Your Grade/Position: *

Your Email Address: *

Details

Nature of the violation of the school’s Child Safety and Personal Protection Policy:

If other, please provide details:

Person Harmed

Name:

Grade/Position:

Parent's Names:

Email Address:

Parent's Phone:

Parent’s company/organization and home country:

Alleged Person/s Causing Harm

Name 1:

Name 2:

Grade/Position 1:

Grade/Position 2:

Relationship to the Offended 1:

Relationship to the Offended 2:

Other Details

How the concern was obtained or observed?

Details of what was reported or suspected:

Please include dates, frequency, location, and what happened as accurately as you can?

Are there any concerns regarding the accessibility of the person who has done the harm to the person(s) who has been, or is being harmed?

Is there any other information you would like the school to be aware of?

Thank You

Thank you for taking the time to complete this reporting form. Dalat will follow procedures as outlined in the Child Safety & Personal Protection Handbook in processing this form. Please understand that an administrator, counselor, or Child Safety Team member may meet with you to further understand the situation.

Date Submitted:

Child Safety Form

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