MODEL COMPLAINTS REFERRAL FORM (SEXUAL EXPLOITATION AND ABUSE)

Name of Complainant: ______________________ Ethnic origin/Nationality: __________________

Address/Contact details: __________________________________________________________

Identity no: __________________________ Age: _____________ Sex: ____________________

Name of Victim (if different from Complainant): _________________________________________

Ethnic origin/Nationality: __________________________________

Address/Contact details: __________________________________________________________

Identity no: __________________________ Age: _____________ Sex: ____________________

Name(s) and address of Parents, if under 18: __________________________________________
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Has the Victim given consent to the completion of this form? O YES O NO

Date of Incident(s): ______________________ Time of Incident(s): ___________________
Location of Incident(s): ___________________________________________________________

Physical & Emotional State of Victim (Describe any cuts, bruises, lacerations, behaviour, and mood): ____________________________________________________________________________
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Witnesses' Names and Contact Information: ____________________________________________________________________________
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Brief Description of Incident(s) (Attach extra pages if necessary): ____________________________________________________________________________
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Name of Accused person (s): _____________________________________________________

Job Title of Accused person(s): ___________________________________________________

Organization Accused person(s) Works For: _________________________________________

Address of Accused person(s) (if known):__________________________________________

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Age: ____________________ Sex: ______________________________

Physical Description of Accused person(s): ____________________________________________________________________________
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Have the police been contacted by the victim? O YES O NO
If yes, what happened? ____________________________________________________________________________
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If no, does the victim want police assistance, and if not, why? ____________________________________________________________________________
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Has the victim been informed about available medical treatment? O YES O NO
If Yes, has the victim sought Medical Treatment for the incident? O YES O NO
If Yes, who provided treatment? What is the diagnosis and prognosis? ____________________________________________________________________________
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What immediate security measures have been undertaken for victim? ____________________________________________________________________________
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Who is responsible for ensuring safety plan (Name, Title, Organisation): ____________________________________________________________________________
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Any other pertinent information provided in interview (including contact made with other Organisations, if any): ____________________________________________________________________________
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Details of referrals and advice on health, psychosocial, legal needs of victim made by person completing report:____________________________________________________________________________
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Report completed by:
Name____________________________________________
Position/Organisation ________________________________
Date/Time/Location_____________________________________________

Has the Complainant been informed about the Ogranisation's procedures for dealing with complaints? O YES O NO

Signature/thumb print of Complainant signaling consent for form to be shared with relevant management structure* and SRSG/RC/HC:

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Complainant's consent for data to be shared with other entities (check any that apply): ____________________________________________________

O Police
O Camp leader (name) ________________________________________
O Community Services agency _________________________________________
O Health Centre (name) ______________________________________
O Other (Specify) ________________________________________________

Date Report forwarded relevant management structure*:

Received by relevant management structure*:
Name _____________________ Position ________________
Signature

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(*Relevant management structure is the official(s) responsible for sexual exploitation and abuse issues in the Headquarters of the Organisation where the Accused person works)

ALL INFORMATION MUST BE HELD SECURELY AND HANDLED STRICTLY IN LINE WITH APPLICABLE REPORTING AND INVESTIGATION PROCEDURES