Home Reportable Conduct Make a Notification

Make a Notification

Using your own form? Upload to our Secure Dropzone. For more details see the instructions at the bottom of this page.

For assistance with completing the Notification Form, please see: Guide for completing the Reportable Conduct Notification Form

Fields marked with an asterisk (*) are mandatory.

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

If other gender, please specify:ENCRYPTED

3.4 Does the alleged victim have a disability?: ENCRYPTED

3.5 Is the alleged victim culturally and linguistically diverse?: ENCRYPTED

3.6 Does the alleged victim identify as Aboriginal or Torres Strait Islander?: ENCRYPTED

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

Provide the details of the second alleged child victim (if known)

3.7 Full name of the alleged victim (if known):ENCRYPTED

3.8 Date of birth of the alleged victim (if known):ENCRYPTED

3.9 Alleged victim's gender: ENCRYPTED

If other gender, please specify:ENCRYPTED

3.10 Does the alleged victim have a disability?: ENCRYPTED

3.11 Is the alleged victim culturally and linguistically diverse?: ENCRYPTED

3.12 Does the alleged victim identify as Aboriginal or Torres Strait Islander?: ENCRYPTED

Add Alleged Victim 3

Provide the details of the third alleged child victim (if known)

3.13 Full name of the alleged victim (if known):ENCRYPTED

3.14 Date of birth of the alleged victim (if known):ENCRYPTED

3.15 Alleged victim's gender: ENCRYPTED

If other gender, please specify:ENCRYPTED

3.16 Does the alleged victim have a disability?: ENCRYPTED

3.17 Is the alleged victim culturally and linguistically diverse?: ENCRYPTED

3.18 Does the alleged victim identify as Aboriginal or Torres Strait Islander?: ENCRYPTED

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:

4.3 Type of allegation or conviction:* Sexual offence

4.3 Type of allegation or conviction:* Sexual misconduct

4.3 Type of allegation or conviction:* Physical assault committed against, with or in the presence of, a child

4.3 Type of allegation or conviction:* Significant neglect of a child

4.3 Type of allegation or conviction:* Any behaviour that causes significant emotional or psychological harm to a child

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

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

6. Supporting documents

Any supporting documents can be uploaded here.ENCRYPTED

You will not receive a copy of your notification after submission. If you would like to a copy of your notification before clicking Submit, click Print page

Use your own form

You can upload your own form to the Ombudsman's secure dropzone. Follow the instructions below:

Go to the Ombudsman's secure dropzone. This facility encrypts the documents you send to us. For the security of sensitive information, please do not email your documents.
Upload the your form and any supporting documents.
Click Submit.

For further information or assistance about notifying the Ombudsman about reportable allegations and reportable convictions, please call us on 08 9220 7471 or email ReportableConduct@ombudsman.wa.gov.au.


FREECALL 1800 117 000	PHONE (08) 9220 7555	mail@ombudsman.wa.gov.au	PO Box Z5386 St Georges Terrace PERTH WA 6831
National Relay Service and quote 08 9220 7555		Translating and Interpreting Service (TIS) 131 450	More contact information

Ombudsman Western Australia

Make a Notification

Use your own form