CHCLEG001 Reasonable Suspicion of Child Abuse and Neglect Assessment Task
I am a worker of the __________________________________________________________________ and I have become aware, or reasonably suspect, that the following child/ren: _______________________________________________
- have/has been harmed; or
- are/is at risk of being harmed.
1. DETAILS OF CHILD/REN AND FAMILY (complete all that are known)
| Child/ren’s names including aliases (write ‘unborn child’ if child is not yet born) | Gender | Age and/or date of birth (if known) | Cultural Identity (if known) |
| Parent/s or carer/s names including aliases | Gender | Age and/or Date of Birth (if known) | Cultural Identity (if known) |
1. Child/ren’s usual address and contact details (if known):
2. Are the child/ren living in more than one household (if known): If yes, what is the other address (including contact details and which child/ren reside there)?
3. Details of other relevant person/s and household member/s:
4. Current location of children (if known):
5. Alleged person/s responsible (if known) and their relationship to the child/ren:
6. Current location of alleged person/s responsible (if known):
7. School (including grade) or Child Care details (if known):
2. ABUSE TYPE BEING REPORTED (more than one may be ticked)
Suspected: o Physical abuse o Emotional abuse o Sexual Abuse o Neglect
At risk of: o Physical abuse o Emotional abuse o Sexual Abuse o Neglect
Source of information: (please circle any that apply, if applicable)
Direct Observation Deduction Hearsay from others
1. Explain what you saw, heard, were told about the child/ren: (attach additional pages if necessary)
2. Outline the impact you believe the events above have had or may have on the child/ren: (attach additional pages if necessary)
3. YOUR DETAILS
Name and work telephone number:
1. What is your agency’s current involvement with the child/ren or family:
2. Please provide a brief summary of the history of your or your agency’s involvement with family and/or child/ren that may be relevant to the Department of Communities – Child Safety Services (eg. Details of any prior domestic violence incidents; criminal history; unexplained injuries).
3. Have you or your agency taken any action to protect the child/ren? If yes please provide details:
4. Names and contact details of any other persons or services who can provide additional information:
5. Are the parent/s aware of your agency’s referral to Department of Communities – Child Safety Services?
6. Would you like the Department of Communities – Child Safety Services to contact you and advise the outcome of this referral?
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