Historic Child Abuse/Inappropriate Behavior
Incident Report Form
Please fill this form out with only the information that is known at the time the report is received. It is understood that there will be blanks or missing information and that is okay. Once filled out and sent to the Child Safety Office, please wait for further instructions.
This report should be completed for reports of possible abuse, neglect or inappropriate behavior no matter how minor, how preliminary, and even if the person who demonstrated the detrimental behavior(s) was a minor at the time or is now deceased. It is to be submitted to the Child Safety Office.
Mail to: SIL International, Child Safety Office, Key 100, 7500 W Camp Wisdom Rd, Dallas, TX 75236
child-safety_intl@sil.org Phone: 972-708-7688 Confidential Fax: 972-708-7391
Date this report is being made: _________________________________________________________
Date(s) the detrimental behavior reportedly occurred: ______________________________________
Branch/entity where the incident(s) occurred: _____________________________________________
Entity Director’s name at the time of the incident(s) (if known): _______________________________
Person filling out this report form:
Your name: _________________________________________________________________________
Your relationship with the individuals listed below: _________________________________________
The organization you were associated with at the time of the incidents and your job position at that time: ______________________________________________________________________________
The organization you are currently associated with and your job position: _______________________
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Your contact information (email, phone, etc.): _____________________________________________
Is the individual who experienced the detrimental behavior(s) aware you are submitting a report on his/her behalf? ______________________________________________________________________
Is he/she in agreement with the report being made? ________________________________________
Is he/she willing to be contacted? _______________________________________________________
Individual #1 (person who experienced the detrimental behavior(s)):
Individual #1’s name: _________________________________________________________________
Current address: ____________________________________________________________________
Current email: ______________________________________________________________________
Current phone: _____________________________________________________________________
Gender: M F
Birthdate: _________________________________________________________________________
Age: ______________________________________________________________________________
Nationality: ________________________________________________________________________
Job: ______________________________________________________________________________
Marital status and spouse’s name: ______________________________________________________
Children’s names and ages: ____________________________________________________________
Primary language: ___________________________________________________________________
Age(s) when the incident(s) occurred: ____________________________________________________
Grade(s) in school when the incident(s) occurred: __________________________________________
City and country in which the incident(s) occurred: _________________________________________
Relationship with individual #2 at time of incident(s): _______________________________________
Describe the relationship with individual #2 at this time: _____________________________________
Individual #1’s Parents’ names: _________________________________________________________
Individual #1’s Parents’ address: ________________________________________________________
Individual #1’s Parents’ phone: _________________________________________________________
Individual #1’s Parents’ primary Member Organization and home country: ______________________
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Names and ages of other siblings: _______________________________________________________
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Individual #2 (person who demonstrated the detrimental behavior(s)):
Individual #2’s name: _________________________________________________________________
Current address: ____________________________________________________________________
Current email: ______________________________________________________________________
Current phone: _____________________________________________________________________
Gender: M F
Birthdate: __________________________________________________________________________
Age: ______________________________________________________________________________
Nationality: ________________________________________________________________________
Job: _______________________________________________________________________________
Marital status and spouse’s name: ______________________________________________________
Children’s names and ages: ____________________________________________________________
Primary language: ___________________________________________________________________
Age(s) when the incident(s) occurred (if known): ___________________________________________
Job position(s) during time of incident(s): _________________________________________________
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City and country in which the incident(s) occurred: _________________________________________
Relationship with individual #1 at time of incident(s) (coach, teacher, youth leader, etc.): ___________
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Describe relationship with individual #1 at this time: ________________________________________
Individual #2’s Primary Member Organization and home country: _____________________________
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Report:
Describe specifically what occurred, including where, when, specific actions, number of times it occurred, any threats, etc. _____________________________________________________________
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Date, time and setting of incident(s): ____________________________________________________
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Anecdotal records that support suspicion of abuse/neglect/inappropriate behavior by individual #2?
__________________________________________________________________________________
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Did individual #1 tell anyone at the time of the incident(s) and what was his/her response? If individual #1 was unable to tell anyone at the time, what factors prevented him/her from getting help at the time? _____________________________________________________________________________
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Who has individual #1 told since then? What was his/her/their response(s)? ____________________
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What factors contributed to individual #1 making this report to SIL at this time? __________________
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Previous reports:
Has individual #1 experienced other abuse/neglect/inappropriate behavior in the past? If so, please describe: __________________________________________________________________________
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Is individual #1 aware if individual #2 has been accused or convicted of other abuse/neglect/ inappropriate behavior in the past? If so, please describe. ____________________________________
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Others potentially affected:
Are there any other persons individual #1 suspects might be involved or affected by the inappropriate actions and/or behavior(s)? (classmates, siblings, others who were in the same location, attended the same events, etc.): ___________________________________________________________________
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Has individual #1 been in recent contact with these other persons listed above? If so, who and when?
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Others with knowledge of the report:
Who else knows about the detrimental behavior(s) individual #1 experienced? List name, their relationship, job, phone, contact information. _____________________________________________
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Has it been reported to a government, law enforcement or child protective service agency? If so, list agency name, name of person the report was given to, agency address, phone number, email address. Also list name, job, and phone number of the person who gave the report, and the report reference number if known. ____________________________________________________________________
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Family dynamics:
Describe the parents’ (of individual #1) reaction to the individual #1’s report (if s/he reported it to them). If he/she has not reported it to his/her parents, why not? ______________________________
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Support system:
Describe the individual #1’s support system (relatives, community, church, etc.) __________________
__________________________________________________________________________________
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Describe any counseling and/or support provided to individual #1. _____________________________
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Additional information: (use additional paper if needed)
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