Child Safeguarding Incident Report

Child Safeguarding Incident Report

This form will be sent to Wonder Connection's Safeguarding Children Officer, Katie Stoudemire.
Information about person submitting this form
Your Name*
Please understand that this form is not for anonymous reporting.
Your Position/Role*
Your Email
example@example.com
Your Phone Number*
Please enter a valid phone number.
Information about the Child/Teen you are concerned about

(if known)
Name of child/teen
Gender
Age
Location

UNC Hospitals (please add room # below)Guest at Ronald McDonald House of Chapel HIllRoom # or other info
Report Details
Are you reporting your own concerns or responding to concerns raised by someone else?*

Reporting my own concernsReporting concerns raised by someone else
If responding to concerns raised by someone else, please provide their name, role and contact details:
Name, role, contact details
When did the incident occur?
Where did the event occur? Please include as many details as possible.
What did you witness (what did you hear, see, notice)? Please include as many details as possible. *
Please provide details including times, dates and other relevant information. Please make it clear whether you are giving a fact, expressing an opinion or an opinion of someone else.
If the child disclosed information to you, please provide the child's account of what happened (e.g. of any incident, injury, disclosure, behavior).
Please provide information about the person alleged to have caused the incident/injury if known (e.g. name(s), address, organization & role, relationship to child)
Please provide the details (name, role, contact details if known) of any witness to the incident/concerns.
Any Actions Taken Thus Far
State any risk of immediate danger. Is the child safe where they are?*
Was any emergency medical attention required?
Who else knows? Please provide names and contact information.
This was already reported to:

The child/teen's nurseBEACON Hotline at UNCRonald McDonald House of Chapel Hill exec. director or manager on dutyDepartment of Social ServicesOther
Any other information or comments.
Signature*

Clear
Date this form is being submitted*

MonthDayYear
Date
ADDITIONAL OPTIONS FOR REPORTING:
You can report any concerns to your local county Department of Social Services.

If the affected child is a:

Patient at UNC: Report to the child’s nurse or BEACON hotline 984-974-0470

Guest at the Ronald McDonald House of Chapel Hill: Report to executive director Heather Shanahan or the manager on duty (919-913-2040)

Wonder Connection participant: Report to Report to child safeguarding officer and project director Katie Stoudemire (919-914-0015)

If you have a concern regarding behavior of Wonder Connection staff or volunteers, please contact Sean @ SEE (our fiscal sponsor). Sean’s email is: sean@saveourplanet.org
Should be Empty:

Child Safeguarding Incident Report

Information about person submitting this form

Information about the Child/Teen you are concerned about

Report Details

Any Actions Taken Thus Far

ADDITIONAL OPTIONS FOR REPORTING: