Report of Suspected Child Abuse - Happyville Community Centre
Child's name:	Justin Marks
Date of birth:	01/04/20XX (Age 4)
Address:	23 The Avenue, HAPPYVILLE, VIC, 3222
Reasons for concern:
What are the family circumstances?
Record of staff member observations:
Record of conversation of disclosure:
Assessment of risk of harm to the child now
Current location	At the centre - due to be picked up at 4 p.m. this afternoon when the program ends.
Information of any known history of abuse
Other relevant information (if applicable)
Name of the person recording information
Signature:
Date:	(Make an estimate of when this information should be recorded - date of Justin's disclosure and report to supervisor Ian was the morning of 3rd April 20XX.)