Suspected abuse or exploitation of a child or vulnerable adult

Any suspicion or concern of abuse or exploitation of a child or adult involving Caritas staff[1] and collaborators[2 ] must be reported as required by the Caritas Africa Complaints Policy and Procedure and the Safeguarding Children and Vulnerable Adults Policy. If you can’t fill in all the sections, please indicate what you know. If there is more than one victim, please complete a separate report for each victim. The identity of the reporter will only be disclosed on a “need to know” basis. If you, the reporter, believe that there is imminent danger to yourself or anyone else involved, you should immediately notify the Secretary General of Caritas Africa. Caritas Africa is committed to processing and responding to all reports.

If there is an immediate threat to life or if emergency assistance is needed, please contact your authorities and alert local senior management immediately. The purpose of this Report Form is to bring any suspected abusive or exploitative activity to the attention of Caritas Africa for evaluation and action.

REPORTED BY: Does the reporter wish to be identified?
Select your optionYesNo
If yes, name and contact information of the reporter: First name
Last name of the reporter
Telephone number (Include area code or country code) (Primary) of the reporter
E-mail from the reporter
Name of the reporter’s organization
Name of the reporter’s position
VICTIM: Is the victim a child or an adult*?
Select your optionChildAdult
Identity of the victim. First name of the victim *:
Last name of the victim *:
(If you cannot provide information about the identity of the victim, check the “Identity Unknown” box).

Approximate age of the victim: (The term “child” refers to anyone under the age of 18.)
Sex of the victim:
Select your optionMaleFemale
Bring any additional information here. Caregiver/Parent* :
(If you cannot provide information on the identity of the caregiver/caretaker/dependent parent,
check the “Identity Unknown” box).

Physical address of the Caregiver/Caretaker/Parent*: (e.g. village name, street name, city, house, building)
Telephone Number (Include area code or country code) (Primary) of Caregiver/Caretaker/Parent* :
Caregiver/Caretaker/Parent* E-mail
Approximate age of caregiver/guardian/parent*.
Gender of Caregiver/Guardian/Parent*:
Select your optionMaleFemale
DETAILS OF THE INCIDENT. Type of incident *: (Check all that apply)

Location of the incident. Address/Physical location of the incident (e.g. village name, street name, city, house, building)
Country Incident location * :
Approximate date of incident:
Date of incident report * :
Physical and emotional state. Physical and emotional state of the victim (Check all that apply)

Please describe in detail the victim’s physical and emotional condition*.
Impairment or disability: Does the victim have a physical impairment or disability*?
Select your optionYesNoDon’t know
If yes, describe the impairment or disability.
Circumstances of the knowledge of the incident *:
Select your optionHe witnessed it Other (to be defined)
To be defined
Victim Safety: Was the victim in immediate danger before this form was completed?
Select your optionYesNo
Have the appropriate authorities and senior management been contacted (if applicable)?
Select your optionYesNo
Please provide any additional information here.
SUSPECT. First and last name of suspect *
Identity unknown (If you cannot provide information on the identity of the suspect, check the
Unknown identity” box).

Telephone number (Include area code or country code) (Primary) of suspect
E-mail of the suspect
Approximate age of suspect:
Sex of the suspect:
Select your optionMale Female
Physical Description of Suspect:
Physical address of the suspect (e.g. village name, street name, city, house, building)
Suspect Organization Name:
Suspect’s job title:
ADDITIONAL INFORMATION: Does anyone else have additional information*?
Select your optionYesNo
If yes, give details:
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[1] Staff includes staff, volunteers, interns and governance members.

[2] Collaborators refer to consultants and contractors.