Reporting form

If you need to report a concern, please complete this form.

Reports submitted through this website may not receive an immediate response. If the child requires emergency assistance, please contact your local authorities or local emergency services first and then fill out the form.
Submitting a report using this form does not satisfy any federal or state legal requirements regarding the reporting of child abuse or neglect.

Do not fill out this form without first carefully reviewing how the reporting process functions and how your report will be handled. Learn more here.

1.ABOUT YOU

Your name:

Your role in Arigatou International:

Country:

Nature of your contact with the child:

Telephone:

E-mail:

2.ABOUT THE CHILD

Child’s name:

Child’s gender:

Child’s age:

Child’s parents/guardians name:

Child’s parents/guardians telephone:

Child’s parents/guardians E-mail:

3.ABOUT YOUR CONCERN

Was it observed by you or was it disclosed to you by someone else?:

If the concern was shared by someone else, please state who and their relationship to the child.

What happened? Give cause (how and why), if known - If you include personal observations please make a distinction between what is a fact and what is opinion or hearsay (e.g. child’s emotional state, visible injuries, etc.)

Did the child or another source say anything to you [if relevant] and how did you respond to him or her? Register only the actual details of what was said or observed.

Has any treatment been given to the child?

In case your answer was positive please fill in the following
Treatment given by:

Was the child taken to a hospital?

If yes, which hospital:

What was the diagnosis?

4. ABOUT THE CIRCUMSTANCES
Date and time of the event/issue::

Location of the event/issue:

Name of the alleged perpetrator and relationship with the child (if applicable):

Were there any other children/people involved in the issue being reported? If yes, please identify them (Name and relationship with the child).

Might there be any other children at risk of harm?

Describe any action taken by you:

Date you submit this report:

I hereby confirm that all of the information provided by me in this form is true and correct to the best of my knowledge.

I declare that I have read the information about how the reporting process functions and I give my consent for my report to be handled as stated therein.

Reporting form

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