Complaint Form - Child Safety

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Work Entry

Your Name

Your Phone Number

Your Email

Affected child or young person in the complaint

Child Name

Age

Gender

Complaint Details

Name of the person the complaint relates to (if applicable):
Please accurately record the issues, who was involved in the incident or complaint and their role, details of any witnesses, etc, as far as possible in the child/young person’s own words/ or in your own words:

Diversity details relating to the affected child or young person

If any of the following are relevant to how we can best support the child or young person, please let us know.

Do they identify as Aboriginal or Torres Strait Islander?

Are they from a culturally and linguistically diverse background?

Are they in out-of-home care?

Do they have a disability?

Do they have communication support needs?

Do they have an alternative preferred sexual orientation and/or gender identity?

Provide any other relevant information relating to the child or young person that can assist in addressing the complaint: