1. Details of organisation
We have provided a guideline on organisations (relevant entities) if you need any assistance in completing this part of the form.
1.1 Name of organisation:*
1.2 Address of organisation:*
1.3 Name of head of organisation:*
1.4 Name of any person from your organisation who you wish to be a contact person for this notification:
1.5 Telephone number:*
1.6 Email of the head of the organisation or the contact person:*
2. Details of the employee who is the subject of the reportable allegation or conviction
We have provided a guideline on employees if you need any assistance in completing this part of the form.
2.1 Full name of the employee (if known): ENCRYPTED
2.2 Any former name or alias of the employee (if known): ENCRYPTED
2.3 Date of birth of the employee (if known): ENCRYPTED
2.4 Employee's Working with Children Check number or application number for a Working with Children Check (if known): ENCRYPTED
3. Details of the alleged victim(s) (if known)
Provide the details of the first alleged child victim (if known)
3.1 Full name of the alleged victim (if known): ENCRYPTED
3.2 Date of birth of the alleged victim (if known): ENCRYPTED
3.3 Alleged victim's gender: ENCRYPTED
Male
Female
Other
If other gender, please specify: ENCRYPTED
3.4 Does the alleged victim have a disability?: ENCRYPTED
Not provided
No
Yes
3.5 Is the alleged victim culturally and linguistically diverse?: ENCRYPTED
Not provided
No
Yes
3.6 Does the alleged victim identify as Aboriginal or Torres Strait Islander?: ENCRYPTED
Not provided
No
Yes
You have the option to add details of further alleged victims below. If you need to add information about more than three alleged victims, please include the details of the alleged victims in a separate document and upload the document at step 6 of this form.
Add Alleged Victim 2
Add Alleged Victim 3
4. Details of the reportable allegation or reportable conviction
We have provided a guideline on reportable allegations or reportable conduct if you need any assistance in completing this part of the form.
4.1 When was the reportable allegation or reportable conviction reported to the head of the organisation?:* ENCRYPTED
4.2 Date of the alleged conduct or conviction (from and to) (if known)
4.2 Date of the alleged conduct or conviction - From:ENCRYPTED
4.2 Date of the alleged conduct or conviction - To:ENCRYPTED
4.3 Type of allegation or conviction:* ENCRYPTED
Select all that apply:
4.4 Details of reportable allegation or reportable conviction:* ENCRYPTED
5. Actions taken to protect children
5.1 Please inform us whether a child is, or children are, currently at risk, and if so, what action have you taken to protect the child or children from risk?:* ENCRYPTED
5.2 Has the reportable allegation or reportable conviction been reported to the Western Australian Police Force?: ENCRYPTED
Yes
No
Unknown
If yes, what date was the report made to police?: ENCRYPTED
5.3 How does the head of the organisation (or their delegate) intend to deal with the allegation or conviction?:* ENCRYPTED