{html-8}

Reporting Staff Member Details:
Name - {text-1}
Position - {text-2}
Date of Report - {date-1}

Details of the Individual Making the Disclosure (if applicable)
Name - {text-3}
Age - {text-4}
Gender - {Select 1}
Contact Information - {textarea-1}
Relationship to Client (if not the client) - {textarea-2}

Details of the Individual Suspected to be Harmed:
Name - {text-5}
Age - {text-6}
Gender - {select-2}
Disability - {text-7}
Contact Information - {textarea-3}
Address - {text-8}
Current Location (if different from address) - {text-9}

Details of the Harm:
Type of Harm - {select-3}
Description of Harm (include any signs, symptoms, or indicators observed): {textarea-4}
Date of Harm (if known): {date-2}
Time of Harm (if known): {text-10}
Location of Harm - {text-11}
Any Known Previous Incidents of Harm - {textarea-5}

Details of the Disclosure (if applicable):
Date of Disclosure - {date-3}
Time of Disclosure - {text-12}
Exact Words Used by the Individual Making the Disclosure (as close as possible) -  {textarea-6}
Behaviour and Demeanour of the Individual Making the Disclosure -  {textarea-6}

Details of the Suspected Perpetrator (if known):
Name - {text-13}
Age - {name-1}
Gender - {select-4}
Relationship to the Individual Harmed - {text-14}
Contact Information - {textarea-8}
Address - {text-15}

Actions Taken:
Immediate Actions Taken to Ensure Safety - {textarea-9}
Who Else Has Been Notified (supervisor, child protection services, police, etc.) - {textarea-10}
Date of Notification - {date-4}
Time of Notification - {text-16}
Any Further Actions Planned or Required - {textarea-11}
Additional Information - {textarea-12}