CAMPLIFE CHILD ABUSE DISCLOSURE REPORT
This information is to be kept confidential.
Staff Occupation
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Child Monitoring & Sponsorships Officer
Community & Family Strengthening Officer
Child Protection & Special Projects Coordinator
Government Field Officer
Community
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Bauleni
Chainda
Chaisa
Chawama
George
Ibex
John Laing
Kabanana
Kamanga
Kanyama One
Kanyama Two
Lusaka West
Matero
Misisi
Mtendere
Ng'ombe
Child Monitoring & Sponsorships Officer
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First Name
Last Name
Community & Family Strengthening Officer
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First Name
Last Name
Government Field Officer
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First Name
Last Name
Select Program
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Legacy Academy
Government
Tree of Life
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Child details
Child Name
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First Name
Last Name
Child ID
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Age
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Gender
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Male
Female
School Term
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Term 1
Term 2
Term 3
Grade
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Newcomer
1
2
3
4
5
6
7
8
9
10
11
12
Class
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A
B
C
D
E
F
G
GCE
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
School
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Bauleni LA
Chainda LA
Chaisa LA
Chawama LA
East LA
George LA
Government
Ibex LA
John Laing LA
Kabanana LA
Kamanga LA
Kanyama One LA
Kanyama Two LA
Lusaka West LA
Matero LA
Misisi LA
Mtendere LA
Ng'ombe LA
North LA
North West LA
South LA
South West LA
Tree of Life
Community
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Please Select
Bauleni
Chainda
Chaisa
Chawama
George
Ibex
John Laing
Kabanana
Kamanga
Kanyama One
Kanyama Two
Lusaka West
Matero
Misisi
Mtendere
Ng'ombe
Status
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Please Select
Single Orphan
Double Orphan
Vulnerable
Caretaker Details
Caretaker
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First Name
Last Name
Age of Caretaker
Relationship with the Child
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Father
Mother
Brother
Sister
Paternal Aunt
Paternal Uncle
Maternal Uncle
Maternal Aunt
Paternal Grandfather
Maternal Grandfather
Paternal Grandmother
Maternal Grandmother
Other
If "Other," specify
Profession/ Nature of Business
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Number of Children in caretaker's home
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Number of Adults in caretaker's home
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Does the caretaker have any disability or health concern?
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Yes
No
If Yes, Explain:
Type of disclosed Abuse
Physical Abuse
Sexual Abuse
Neglect Abuse
Spiritual Abuse
Exploitation
Emotional
All the Above
Other
Details of concern
Are there any changes in the Child's Behavior:
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Yes
No
Explain the changes in the Child's Behavior:
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Are there any physical signs:
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Yes
No
If Yes, Explain the Physical Signs:
Child's Report (Including child's words if possible)
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Is there any alleged Perpetrator?
Yes
No
Perpetrator's Name
First Name
Last Name
Relationship with the Child
Kindly share any additional information about the Perpetrator:
Do you feel safe at home?
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Yes
No
Action recommended
Has the child received medical attention?
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Yes
No
If Yes, provide any relevant medical information:
Is there anyone that knows about this information you have shared?
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Yes
No
Person's Name
First Name
Last Name
Relationship with the Child
Kindly share any additional information about the Person:
Details of action
Has this concern been reported to the police or Victim Support Unit (VSU) at UTH?
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Yes
No
If No, why has the situation not been reported?
If Yes, have you collected medical form from Victim Support Unit (VSU)?
Yes
No
Has the Child Protection Deputy Program Manager been informed?
Yes
No
Has any partner organization been informed?
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Yes
No
Action 2: (Child Protection)
Details of Action
What further action need to be taken?
Outcome
Child protection handling the case
First Name
Last Name
Child protection handling the case signature
Date
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Month
-
Day
Year
Date
Staff at Camplife
Child Monitoring & Sponsorships Officer's Signature
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Date
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-
Month
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Day
Year
Date
Community & Family Strengthening Officer's Signature
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Date
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-
Month
-
Day
Year
Date
Government Field Officer's Signature
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Date
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-
Month
-
Day
Year
Date
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