PRIVATE AND CONFIDENTIAL
SP-4: REPORT OF SUSPECTED HARM OR RISK OF HARM
In accordance with Section 22 of Child Protection Act 1999
Date: 1 January 1011
Region: Demonstration Region
School: Sunny Gardens State School
School phone: 07 3111 1111
School fax: 07 3111 0000
DETAILS OF STUDENT HARMED OR AT RISK OF HARM:
Legal Name: Gregory Smith
Preferred Name: Greg Smith
DOB: 20/3/2004
Male
Year Level: 3
Aboriginal
Female
Cultural background:
Torres Strait Islander
Aboriginal and Torres Strait Islander
Does the student have a disability verified
under EAP:
Yes
No
Student’s Residential Address:
Sunny Gardens Caravan Park
SUNNY GARDENS QLD 4444
Disability category:
Phone: 1234 111 111
Student’s Personal Mobile:
FAMILY DETAILS
Parent/caregiver 1: Mary Smith
Relationship to student: Mother
Address (if different from student):
Phone: (H):
(W):
(M): 0418 111 111
Parent/caregiver 2:
Relationship to student:
Address (if different from student):
Phone: (H):
(W):
Is the student in out of home care:
(M):
Yes
No
OTHER HOUSEHOLD MEMBERS: (All known names of children, family and significant others).
Date of
Relationship to
Name
Sex
School
Birth
student
PERSON ALLEGED TO HAVE CAUSED THE HARM OR RISK OF HARM
Adult family member
Child family member
Student/other child
Unknown
Other adult
Version: November 2011
Page 1 of 3
Uncontrolled copy. Refer to: SMS-PR-012: Student Protection at http://education.qld.gov.au/strategic/eppr/students/smspr012/ for
master.
TRIM 11/254594
PRIVATE AND CONFIDENTIAL
SP-4: REPORT OF SUSPECTED HARM OR RISK OF HARM
In accordance with Section 22 of Child Protection Act 1999
Provide all information you have which led to the suspicion of harm or risk of harm (attach extra pages if
necessary).
.
Details of any harm and/or risk of harm to the student – Please include: Time and date of incident, source of
information, details of person alleged to have caused the harm, physical appearance of any injury, immediate and ongoing safety
concerns, any disclosures made by student, any previous incidents of harm, behavioural indicators of harm, presence of any medical
needs or developmental delays, and if the information relates to an unborn child, the alleged risk to the unborn child
Greg came to school with his arm in a sling. He said he had fallen off his bike. Last week he was absent for
two days. When he returned he had a black eye and said he had fallen off his bike. Last year Greg had a cut
on his head and again he reported that he had fallen off his bike. Greg frequently presents as scruffy and
smells of stale urine. Greg is often aggressive towards his peers.
Details of parent/carer’s circumstances – e.g. parenting capacity; protective capacity; presence of complicating factors
including domestic violence, drug/alcohol misuse; mental health history; physical or intellectual disabilities, family stressors – financial,
isolation, accommodation, unemployment, family law disputes; mobility and transience
Mother told the school that she and Greg had moved to the area to get away from mother's abusive
boyfriend. Greg has poor impulse control which mother appears to have limited ability to manage. Mother
does not have a lot of external supports. Grandparents do not live close and school is unaware of any other
agencies that may be supporting the family.
Parent/carer knowledge of incident and their response
Mother provided a note on return to school last week indicating that Greg had fallen off his bike. Other
incidents have not been discussed with mother.
Details of environmental factors – e.g. condition of home, access to student by person alleged to have caused harm,
presence of parent/household member able and willing to protect the student;
Greg lives at the local caravan park where he has resided with his mother for just over 2 years. He often
does not have money for school excursions.
Other services or supports currently in place to support the student – Please include contact with other
professionals (police, medical, community)
School is not aware of any agencies supporting the family.
Additional information provided as an attachment
Yes
No
Notifier 1 Name: Peter Smith
Position: Yr 3 Teacher
Notifier’s email: xyz@eq.edu.au
Signature:
Date: 1/1/11
Notifier 2 Name: Mary Brown
Position: Principal
Notifier’s email: abc@eq.edu.au
Signature:
Date: 1/1/11
ACTION TO BE TAKEN (Tick the appropriate suspected harm/risk of harm type below)
Physical abuse
Sexual abuse
Fax or email this form to:
 Department of Communities (Child Safety Services)
 Queensland Police Service (QPS)
 Regional Director
Version: November 2011
Page 2 of 3
Uncontrolled copy. Refer to: SMS-PR-012: Student Protection at http://education.qld.gov.au/strategic/eppr/students/smspr012/ for
master.
TRIM 11/254594
PRIVATE AND CONFIDENTIAL
SP-4: REPORT OF SUSPECTED HARM OR RISK OF HARM
In accordance with Section 22 of Child Protection Act 1999
Emotional abuse
Neglect – includes self-harm
where parent/carer not acting
protectively
Fax or email this form to:
 Department of Communities (Child Safety Services)
 Regional Director
Confirm receipt of faxed or emailed form and ensure original SP4 is stored in a secure location along with any other
documentation collected for the purpose of this report.
Version: November 2011
Page 3 of 3
Uncontrolled copy. Refer to: SMS-PR-012: Student Protection at http://education.qld.gov.au/strategic/eppr/students/smspr012/ for
master.
TRIM 11/254594