SAMPLE

Safe Church Concerns Anecdotal Record

Complete and give to your Team Leader
The completed form should be given to the team leader, who will pass the information onto
the Safe Church Concerns Person. To be kept in a locked filing cabinet.
Name of organisation (church):
Safe Church Contact Person:
Name of team leader :
Name of leader filling in this form:
Details of person report is concerning:
Leaders relationship to the person:

Describe your concerns, what was observed or what was said. Include dates/times
where applicable.
It is important to provide as much information as possible, basing your information
on facts and observations, without making assumptions or jumping to conclusions
or making value judgments.

Is a child at risk of significant harm report to Community Services warranted? Yes/No

What follow up will happen? Who?

...

Time and Date of Recording: