When completing this form any information which you feel would directly identify the respondent or complainant should be removed

 

About the suspicion/concern/knowledge/allegation
Date of suspicion/concern/knowledge/allegation:

 

Date information received:

 

Date sent to NBSCCCI

 

 

Details of complainant
DOB:

 

Age at the time of the suspicion/concern/knowledge/allegation:

 

 

Details of respondent (Name can be anonymised with notifying the NBSCCCI)
Name:

 

Name of Church body at time of the suspicion/concern/knowledge/allegation:
 

Name of current Church body (if different from above):

 

DOB/age:

 

Date of Death if applicable:

 

Relationship to complainant (parent/priest/teacher, etc):

 

Role in Church body (priest in parish/brother/sister/teacher in school):
 

Current contact with children if known (e.g. sits on board of governors of school, runs youth activities etc):

 

Any additional Information

 

 

 

 

Details of suspicion, concern, knowledge or allegation

(Include dates/times the incident occurred; the type of abuse that is being alleged (sexual, physical,  emotional or neglect); any witnesses(anonymised), if known; and whether the complainant knows this referral is being made?)

 

 

 

 

 

 

Referral to the statutory authorities

Has the matter been referred to the statutory authorities? Yes No

If the answer to the question above is yes, please complete the details below. If the answer is no, please explain why the matter was not referred to the statutory authorities.

 

Tusla Gardaí

 

Date referred: Date referred:
Time referred: Time referred:
Name of person it was referred to: Name of person it was referred to:
Designation: Designation:
Address: Address:
Telephone Telephone
Email: Email:

 

Referral to member of the Church (ONLY COMPLETE IF THE ALLEGATION RELATES TO CHURCH PERSONNEL)
Has the matter been referred to the Bishop          Yes   No
Name of Diocese:
Date referred:
Time referred:
Name of person it was referred to:
Designation:
Address:
Telephone:
Email:

 

Next steps (ONLY COMPLETE IF THIS ALLEGATION RELATES TO A CLERIC OR RELIGIOUS)

What actions have been taken (if any) by the Church, in relation to the respondent, to safeguard children following receipt of this information?

 

 

 

Sign off for DLP Sign off for Mandated Persons (ROI only)
DLP name: This section must be completed if the person making the referral is a mandated person (as defined in Children First 2015)
DLP Address:
DLP telephone: Name:
DLP Email: Signature:
DLP Signature: