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Incident Report Form

It is not possible to make an anonymous incident report using this form. All incident reports will be managed confidentially and stored securely

Date of incident
Month
Day
Year

If unsure of the exact date, please choose an approximate date and make a note of this in the comments field below.

Type of incident

One or more selections may be made.

E.g. In the church grounds, in the sanctuary, in the church hall, at a church BBQ

E.g. The name of the person causing physical injury or emotional discomfort, any witnesses

Do you have further information that you wish to provide?
Yes - I consent to a Child Safety Contact Person contacting me to obtain this information
No

E.g. Photographs, medical reports, detailed statements

Has a Child Safety Contact Person already been made aware of the incident?
Yes
No
Unsure

E.g. By being called to the scene of the incident at the time it occurred

Would you like to be contacted further about this incident report?
Yes
No

E.g. Should further information be required, or to be advised of the outcome of the report

Postal Address

Address all correspondence to:

Holy Ascension Orthodox Church
PO Box 234, Keilor East, Victoria 3033

Australia

​© Copyright 2009 - 2025 Holy Ascension Orthodox Christian Mission Centre Inc.

Incorporated Association # A0053809W
 

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