Incident Report
Concord Friends Meeting considers any sexual involvement of an adult with a child to be abuse of the child by the adult. We condemn such behavior. We condemn the non-accidental injury or risk of injury to any child by any adult or caretaker. We condemn any failure by a caretaker to take available action to provide for the care or supervision of a child in their care.
If you suspect that any such abuse or neglect may have occurred, please contact one of the people listed below:
Any Ministry and Counsel Member
Please fill out the following information and share with the people listed above.
Date Written______________________ Written by________________________________ (please print)
Writer’s address and telephone(s)
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Date of the incident_______________________________
Child(ren) Name & D.O.B: _____________________________________________________________________
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Names, address and telephone of parents or custodians:
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Who has custody?__________________________________________________
1. Is the child currently safe? Please describe the situation if the child is not safe.
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2. What needs to happen to get and/or keep the child safe? ___________________________________
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3. What is the nature and extent of injury, abuse, or neglect including any prior evidence of same? (Please cite the source of your information if not observed firsthand.) Where and when did the injury occur? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. What are the circumstances under which you became aware of the injuries, abuse or neglect? _________________________________________________________________________________
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5. Has the child and/or the child’s family been contacted and offered support or information? _________________________________________________________________________________
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6. REPORT TO STATE AGENCY:
Agency called and telephone number: __________________________________________________
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Person spoken to: __________________________________________________________________
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Date and time: ____________________________________________________________________
What is agency’s plan for response? ___________________________________________________
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6. Additional information.
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This form will be stored in a locked file box in the Meetinghouse. ____________________
