Fillable Form 1: OMBUDSMAN Reporting Abuse in Defence Reporting (Public Order and Safety)

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Form 1: OMBUDSMAN Reporting Abuse in Defence Reporting (Public Order and Safety)

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COMMONWEALTH 0
OMBUDSMAN
Reporting Abuse in Defence
Reporting Form
Please complete this form if you are reporting experiences of abuse while employed in the Australian
Defence Force (Defence) to the Defence Force Ombudsman, which you want to be assessed under
the Ombudsman Regulations 2017 (the Regulations).
1
Abuse is defined in the Regulations to mean:
sexual abuse; serious physical abuse; and serious bullying and harassment.
Reports of abuse can be made by, and on behalf of,
2
serving and former members of Defence.
Reports can also be made by Australian Public Service employees or contractors who have been
deployed overseas in connection with Defence activities.
We understand that taking this step to report incidents of abuse is difficult, and recalling experiences
of abuse can be distressing. If you need help to make your report of abuse, or if you have any
questions about the form or need assistance to complete this form, please contact our Liaison team
by calling 1300 395 776 or by email at defenceforce.ombudsman@ombudsman.gov.au. We will work
with you to support you through the reporting and assessment processes.
Our Office may recommend that Defence make a reparation payment in relation to a report of
serious abuse, which has been accepted, if you contact the Office on or before 30 June 2022 and
either:
• Submit a report of abuse you experienced in Defence; or
• Provide written notification that you intend to lodge a report of abuse, which you must then
provide by 30 June 2023.
If you do not submit your report of abuse or an intention to report abuse by 30 June 2022, you
cannot receive a reparation payment.
If you provide a written intention to report abuse, you must submit your report by 30 June 2023 or
you will not be able to receive a reparation payment.
Importantly, to be eligible for a reparation payment, the report of abuse must also be about abuse
allegedly engaged in by a member of Defence on or before 30 June 2014.
There are two possible payments which we may recommend:
• a payment of up to $45,000 to acknowledge the most serious forms of abuse
1
For more information, see our factsheets and FAQs on our website at http://www.ombudsman.gov.au/How-we-can-
help/australian-defence-force/reporting-abuse-in-defence
2
You can nominate an authorised representative to act on your behalf, this may be, for example, a family
member or advocate. This requires you to complete the Permission for another person to act on my behalf
form on page 6.
GPO Box 442, Canberra ACT 2601 ▪ Phone 1300 395 776 ▪ ombudsman.gov.au
•
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• a payment of up to $20,000 to acknowledge other abuse involving unlawful interference
accompanied by some element of indecency.
If we recommend one of these payments, an additional payment of $5,000 may also be
recommended if we are satisfied that Defence did not respond appropriately to the incident of
abuse.
The above payments may be reduced if a reportee has already received a reparation payment
relating to abuse in Defence, such as from the Defence Abuse Response Taskforce.
This form is ready to be submitted when:
you have attached one copy of certified identification
you have answered all of the questions on the reporting abuse form
you have signed the statutory declaration and had it witnessed
you have attached any relevant supporting material (if applicable)
you have attached the signed ‘on behalf of authority’ form (if applicable)
Once you have completed this form, you can submit it to us by:
a. email to: defenceforce.ombudsman@ombudsman.gov.au or;
b. post to: Defence Force Ombudsman, GPO Box 442 Canberra ACT 2601
Further information about reporting abuse in Defence is available on our website at:
http://www.ombudsman.gov.au/How-we-can-help/australian-defence-force/reporting-abuse-in-
defence.
What happens next?
You will be assigned an Ombudsman Liaison Officer, who will remain your dedicated point of contact
through your engagement with our office. You will be contacted if any clarification or further
information is required for assessment. You can choose to put your assessment on hold, or withdraw
it, at any time in the process – just let us know if you change your mind after submitting this report.
December 2020 Page 2 of 26
Use and disclosure of personal information
Personal information of people who contact the Defence Force Ombudsman is treated as
confidential and is managed in accordance with the Privacy Act 1988 (Cth).
Personal information is information about an individual whose identity is apparent or can
reasonably be discovered.
The Defence Force Ombudsman Privacy Policy provides further detail about how your personal
information will be collected and used.
The Commonwealth Ombudsman, as part of its Defence Force Ombudsman jurisdiction, can receive
and assess reports of abuse in Defence. The Office of the Commonwealth Ombudsman is an entity
under the Privacy Act 1988 and is subject to the Australian Privacy Principles (APPs). The APPs set out
standards, rights and obligations for APP entities in relation to handling, holding, accessing and
correcting personal information.
Personal information that the Ombudsman collects and holds, and the purpose of
collection
In relation to reports of abuse, the Ombudsman collects personal information where it is relevant to
discharging our obligations under the Ombudsman Regulations 2017.
This personal information may include the name, address, contact details, date of birth, gender,
occupation, employment history, family background and financial records of individuals who have
reported serious abuse in Defence to the Ombudsman. It may also include information about alleged
abusers and other third parties, such as witnesses to the abuse or individuals to whom the abuse was
reported.
The information which the Ombudsman collects and holds includes some types of sensitive
information (which is a subset of personal information). This may include sensitive information about
an individual’s racial or ethnic origin, political opinions, membership of a political association,
religious beliefs or affiliations, philosophical beliefs, membership of a professional or trade
association, membership of a trade union, sexual orientation or practices, criminal record or physical
or mental health.
December 2020 Page 3 of 26
How the Ombudsman collects personal information
At all times the Ombudsman tries to only collect the information needed for the particular function
or activity we are carrying out under the Regulations. Where it is reasonably practicable to do so, we
collect this information directly from the individual concerned.
People who make reports to the Ombudsman provide us with personal information to enable us to
assess their report of abuse and take appropriate action in accordance with the Regulations. In
appropriate circumstances, personal information may be collected indirectly or from other sources,
such as the Department of Defence, the Department of Veterans’ Affairs or from public records.
Anonymity
Where possible, the Ombudsman allows individuals to interact with us anonymously or to use a
pseudonym. However, for most of our functions and activities associated with assessing and
responding to reports, we will need an individual’s name, contact information and enough
information about them to enable us to fairly and efficiently handle their report.
How the Ombudsman holds personal information
The Ombudsman uses a range of physical and electronic security measures to protect personal
information from misuse and loss, and from unauthorised access, modification or disclosure. These
measures include restricted physical access to our offices, security containers, firewalls, secure
databases, computer-user identifiers and passwords.
The requirements of the Archives Act 1983 relating to Commonwealth records (including the
disposal, alteration and destruction of such records) apply to Ombudsman records, including
personal information held by the Ombudsman. The National Archives of Australia has imposed a
disposal freeze on Commonwealth records potentially related to allegations, handling and
consequences of sexual and other forms of abuse in Defence. Further information regarding the
disposal freeze is available at the Archives website:
http://www.naa.gov.au/Images/Disposal-
Freeze-Defence-R1153352012_tcm16-95250.pdf
December 2020 Page 4 of 26
Certification of documents
A certified copy of a document is a copy (often a photocopy) of a primary document that has on it an
endorsement or certificate that it is a true copy of the primary document.
• Who can certify a copy?
The same person who is eligible to witness you signing a statutory declaration can certify documents.
• How are copies certified?
Before certifying a document, the certifier must ensure the copy is an identical copy of the original.
Suggested wording for the certification is as follows:
I certify that this is a true copy of the document sighted by me on [dd/mm/yyyy]
Signature
Name
Qualification (eg. JP, Pharmacist)
Commonwealth statutory declaration form
A statutory declaration is a written statement which you sign and declare to be true before an
authorised witness.
• Authorised witnesses
Common examples of an authorised witness include a Justice of the Peace, police officer, certain
people working in banks and staff at courthouses. Police stations often have a Justice of the Peace
available at certain times.
• False information
If you intentionally make a false statement in a statutory declaration you can be charged with a
criminal offence which carries the possibility of up to four years imprisonment.
If you would like further information about statutory declarations, please contact our Liaison team
on our dedicated number 1300 395 776, or visit https://www.ag.gov.au/Publications/Statutory-
declarations/Pages/Frequently-asked-questions.aspx.
December 2020 Page 5 of 26
CONSENT FORM
In this form we seek your consent for the Defence Force Ombudsman and other agencies,
persons or bodies, to collect and disclose your personal information for the purposes of
responding to your report.
The Ombudsman requires your consent to approach Defence to confirm your record of service and
to obtain other information relevant to the report. All of your personal information will be kept
confidential by Defence.
Personal information will only be shared if it is necessary and any information shared will be limited
to relevant information. If you have any concerns about providing us with consent please ring
1300 395 776 to discuss them with an Ombudsman Liaison Officer.
I agree and provide my consent to:
My name, a description of the abuse I experienced, and any other personal information I
have provided, being provided to Defence for the purposes of it being able to provide
information relevant to my matter.
My relevant personal information held by any body, person or agency (such as Defence)
being provided for the work of the Ombudsman in facilitating an appropriate response to my
communications.
Any organisation, department, doctor, health professional, hospital or other health
institution or rehabilitation provider, providing the Ombudsman with copies of any reports,
or other relevant documentation, in relation to any treatment provided to me arising from
any incident or injury suffered by me in connection with my service with the Australian
Defence Force or Department of Defence.
Signature:
Full Name:
Date:
December 2020 Page 6 of 26
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Important note: This Reporting Abuse form is set out as a Statutory Declaration. A person who
intentionally makes a false statement in a Statutory Declaration is guilty of an offence, the
punishment for which is imprisonment for a term of up to four years – Section 11 Statutory
Declarations Act 1959 (Cth).
Please provide one certified copy
of proof of your identity:
Please refer to the last page of this form
for details of who may/how to certify
documents
Current driver’s licence
Current concession card
‘Proof of age’ card
Employee identity card issued by an Australian
Government Authority
Current passport identification page
Senior’s card
Other recognised proof of identity
Comments:
The Ombudsman acknowledges that in some circumstances you may not be able to provide proof of
identity documentation because it does not exist or because you live in a remote or isolated area. In
these circumstances you should have a referee
3
complete this section:
I
(Referee’s full name)
of
(Referee’s address)
have known
(Name of person making report)
for __________ year(s)
and confirm this is their signature hereunder
Signature of person
making report:
Date: ___ / ___ /___
Signature of referee:
Date: ___ / ___ /___
3
A referee for this purpose, is someone who can confirm/verify who you are.
December 2020 Page 7 of 26
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Commonwealth of Australia
STATUTORY DECLARATION
Statutory Declarations Act 1959 (Cth)
PERSONAL DETAILS OF PERSON MAKING REPORT
I,
1. Title
2. Last name
3. Given name(s)
4. Gender Male
Female
X (Indeterminate/Unspecified)
5. Date of birth (day/month/year)
6. Current residential address
Unit/Street number and name
Suburb
State/Territory/Other
Postcode
Country, if not Australia
7. Occupation
make the following declaration under the Statutory Declarations Act 1959 (Cth):
December 2020 Page 8 of 26
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ADDITIONAL PERSONAL DETAILS
8. Current postal address (if same,
write ‘as above’)
Unit/Street number and name
Suburb
State/Territory/Other
Postcode
Country, if not Australia
9. Email address
10. Mobile number
11. Home phone number
(include area code)
12. Work phone number
(include area code)
13. Preferred contact method Mobile
Home phone number
Work phone number
Email
Post
Other (please specify)
Comments:
14. Additional instructions for contact
(e.g. email before phone contact,
best times to contact, do not leave a
message)
December 2020 Page 9 of 26
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15. You will be supported by an
Ombudsman Liaison Officer, who
will be your single point of contact
throughout the process - do you
have a specific gender preference
for your Liaison Officer?
Male
Female
No preference
16. Service status Current serving member
Former member
APS employee – deployed overseas
Defence contractor – deployed overseas
Reservist (please specify reserve type
below)
Comments:
17. Service Navy
Army
Air Force
APS (Department of Defence)
Comments:
18. Service/PMKeyS/Employee Number
19. Dates of service/employment Start date:
End date:
December 2020 Page 10 of 26
COMMONWEALTH 0
OMBUDSMAN
•
•
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REPORT
The following is a true and accurate account of the abuse I experienced, which I am reporting to
the Defence Force Ombudsman, for consideration and assessment:
YOUR DETAILS AT THE TIME OF THE INCIDENT(S)
1. What was your name at the time Given name(s):
of the incident(s)?
Surname:
Nickname(s):
2. If you were known by a different
name, please provide details
(e.g. maiden name, formerly
known as)
3. What was your gender at the time
of the incident(s)?
Male
Female
X (Indeterminate/Unspecified)
4. What Service were you in at the Navy
time of the incident(s)?
Army
Air Force
APS (Department of Defence)
Comments:
5. What was your Title/Rank/Level at
the time of the incident(s)?
6. How old were you at the time of
the incident(s)?
GPO Box 442, Canberra ACT 2601 ▪ Phone 1300 395 776 ▪ ombudsman.gov.au
DATE AND LOCATION OF THE INCIDENT(S)
7. Please provide the dates of when the
incident(s) happened?
8. Where did the incident(s) occur?
(e.g. provide the name of the base or
Defence establishment the incident(s)
occurred)
DETAILS OF THE PERSON(S) WHO ABUSED YOU
The following question is asking you to identify anyone who abused you. Please describe in as much
detail as possible. Detail is important.
9. Do you remember the name(s) of the
person(s) who abused you?
Please write what you can to help
identify them.
Given name(s):
Surname:
Nickname(s):
Comments:
10. If you do not know the name of the
person(s) who abused you, please give
a reason why.
(e.g. the person was unknown to me)
December 2020 Page 12 of 26
•
•
•
•
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•
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•
11. What was the gender of the person(s)
who abused you?
Male
Female
X (Indeterminate/Unspecified)
I don’t know
12. Do you know what Service the Navy
person(s) who abused you was in?
Army
Air Force
APS (Department of Defence)
Comments:
13. Do you know the Title/Rank/Level of
the person(s) who abused you?
14. What was this person’s relationship to
you at the time of the incident(s)?
(e.g. Chain of command, Senior officer
etc.)
15. Please provide any additional details
about the person(s) who abused you.
December 2020 Page 13 of 26
DETAILS OF ANY PERSON(S) WHO MAY HAVE KNOWN ABOUT THE INCIDENT(S)
The following question is asking you to identify anyone who may have known about the abuse.
Please describe in as much detail as possible. Detail is important.
16. Do you remember the name(s) of
anyone who witnessed the
incident(s)?
Please write what you can to help
identify them.
Given name(s):
Surname:
Nickname(s):
Comments:
17. Please provide any additional
details about any witness(es).
December 2020 Page 14 of 26
COMMONWEALTH 0
OMBUDSMAN
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REPORTING THE INCIDENT(S)
Please note, there is no requirement to have reported this before submitting this form. Please
describe in as much detail as possible. Detail is important.
18. Did you report the abuse you Yes – please answer questions 20 to 22
experienced?
No, I have not reported my abuse – please
answer question 19
19. Please provide details of any reasons
for your decision not to report the
abuse you experienced.
If you did not report the abuse, you
do not need to answer any further
questions in this section (20 – 22).
20. Did you report the abuse at the time
of the incident or later?
I reported at the time of the incident
I reported the incident later – please provide
details below about when you reported and why
you chose to report at a later time.
Comments:
GPO Box 442, Canberra ACT 2601 ▪ Phone 1300 395 776 ▪ ombudsman.gov.au
•
•
21. Who did you report the abuse to?
Please provide as much detail as
possible.
Defence
(e.g. Commanding Officer, Chaplain, Equity Office,
Colleague)
Comments:
External to Defence
(e.g. the Department of Veterans’ Affairs, the
Defence Abuse Response Taskforce, a Member of
Parliament)
Comments:
22. What was the outcome of your
report?
Please provide as much detail as
possible.
December 2020 Page 16 of 26
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DETAILS REGARDING MEDICAL TREATMENT RELATING TO THE INCIDENT(S)
The following questions are asking you about any medical injuries suffered and treatment sought in
relation to the abuse you experienced. Please describe in as much detail as possible. Detail is
important.
23. What was the nature of any injury or
injuries you suffered from the abuse?
24. Did you seek medical treatment in
relation to any injuries suffered?
Yes – please answer question 26
No – please answer question 25
25. Please provide details of any reasons
for your decision not to seek medical
treatment.
If you did not seek medical treatment,
you do not need to answer question
26.
26. Please provide details of any medical
treatment you received
December 2020 Page 17 of 26
COMMONWEALTH 0
OMBUDSMAN
DETAILS OF THE ABUSE YOU EXPERIENCED
Please describe the incident(s) you have experienced in your own words and in as much detail as
possible. You should write in a way that gives a clear understanding of the abuse that took place.
Please include details of how you were treated, what was said to you, and how often it happened.
Detail is important. A statement like “I was sexually assaulted” needs to be supported by additional
information/detail for us to be able to assess your report and whether it was reasonably likely to
have occurred.
If further information is required, your Ombudsman Liaison Officer will make contact with you. This
may include requesting supporting documents that may be relevant.
27. Please describe the abuse you experienced.
GPO Box 442, Canberra ACT 2601 ▪ Phone 1300 395 776 ▪ ombudsman.gov.au
December 2020 Page 19 of 26
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DETAILS OF ANY PRIOR PAYMENTS YOU HAVE RECEIVED RELATING TO THE ABUSE YOU
HAVE EXPERIENCED
Please tell us about any payments you have received in relation to abuse you have experienced in
Defence. For example:
• Victims of crime payments
• Defence Abuse Response Taskforce (DART) reparation payment
• National Redress Scheme payments (or other redress scheme payments)
• Court awarded payments
• Any other payments
You do not need to tell us about:
• Payments from the Department of Veterans’ Affairs
28. Have you received or applied for any
financial payment in relation to abuse
you have experienced in Defence?
Yes – please answer questions 29 to 32.
No – you do not need to answer any further
questions in this section.
29. Where did this payment come from?
(e.g. DART Reparation payment, civil
litigation)
30. What was the amount(s) paid?
31. When did you receive this
payment(s)?
32. Please provide any other details you
think may be relevant about the
payment(s) you have received.
December 2020 Page 20 of 26
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DETAILS ABOUT WHY YOU HAVE DECIDED TO SUBMIT YOUR REPORT
33. What are you hoping for through this
process? (select all that apply)
Acknowledgement of your experience of
abuse by Defence (which may arise from a
Restorative Engagement Conference
4
)
An apology from Defence (which may arise
from a Restorative Engagement
Conference)
Gain a sense of closure
For my report to contribute to Defence’s
commitment to cultural reform
An assisted referral by our Liaison team to
counselling with Open Arms
A reparation payment (please note: not all
reports of abuse will attract a reparation payment
– for more information about reparation
payments please see the Office website at:
http://www.ombudsman.gov.au/How-we-can-
help/australian-defence-force/reporting-abuse-in-
defence)
Other – provide comments below
Comments:
34. How did you hear about us?
4
For detailed information about a Restorative Engagement Conference, see: http://www.ombudsman.gov.au/How-we-can-
help/australian-defence-force/reporting-abuse-in-defence
December 2020 Page 21 of 26
ADDITIONAL INFORMATION
35. Is there any other information you
would like to provide?
SUPPORTING MATERIAL
Please provide any supporting material that relates to the abuse you experienced. These documents
do not need to be certified.
Documents which can assist the assessment process include:
• your service records (which relate to the incident(s) you have reported in this form)
• medical records (which relate to the abuse you experienced)
• Witness or Police statements (which relate to the abuse you experienced)
If you do not have copies of any of these documents but know who may be able to provide them or
where they can be obtained, please provide this information.
December 2020 Page 22 of 26
COMMONWEALTH 0
OMBUDSMAN
Please note: A person witnessing your signature is only required to see you sign the documents and
sign the signature declaration below. Witnesses are not required to view or read the details provided
in this report.
I understand that a person who intentionally makes a false statement in a statutory declaration is
guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the
statements in this declaration are true in every particular.
3 Signature of person
3
making the
declaration
4 [Optional: email
address and/or
4
telephone number
of person making
the declaration]
5 Place
Declared at
5
on
6
of
7
6 Day
7 Month and year
Before me,
8 Signature of person
8
before whom the
declaration is made
(see over)
9 Full name,
9
qualification and
address of person
before whom the
declaration is made
(in printed letters)
10 [Optional: email
address and/or
telephone number
of person before
whom the
10
declaration is made
Note 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the
punishment for which is imprisonment for a term of 4 years — see section 11 of the Statutory Declarations Act
1959.
Note 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 — see
section 5A of the Statutory Declarations Act 1959.
GPO Box 442, Canberra ACT 2601 ▪ Phone 1300 395 776 ▪ ombudsman.gov.au
A statutory declaration under the Statutory Declarations Act 1959 may be made before–
(1) a person who is currently licensed or registered under a law to practise in one of the following occupations:
Architect Chiropractor Dentist
Financial adviser Financial Planner Legal practitioner
Medical practitioner
3 of Part 3 of the Migration A
Midwife
ct 1958
Migration agent registered under Division
Nurse Occupational therapist Optometrist
Patent attorney Pharmacist Physiotherapist
Psychologist Trade marks attorney Veterinary surgeon
(2) a person who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Australia, as a legal
practitioner (however described); or
(3) a person who is in the following list:
Accountant who is:
a) a fellow of the National Tax Accountants’ Association; or
b) a member of any of the following:
i. Chartered Accountants Australia and New Zealand;
ii. the Association of Taxation and Management Accountants;
iii. CPA Australia;
iv. the Institute of Public Accountants
Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public
APS employee engaged on an ongoing basis with 5 or more years of continuous service who is not specified in another
item in this list
Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955)
Bailiff
Bank officer with 5 or more continuous years of service
Building society officer with 5 or more years of continuous service
Chief executive officer of a Commonwealth court
Clerk of a court
Commissioner for Affidavits
Commissioner for Declarations
Credit union officer with 5 or more years of continuous service
Employee of a Commonwealth authority engaged on a permanent basis with 5 or more years of continuous service who is
not specified in another
item in this list
Employee of the Australian Trade and Investment Commission who is:
(a) in a country or place outside Australia; and
(b) authorised under paragraph 3 (d) of the Consular Fees Act 1955; and
(c) exercising the employee’s function at that place
Employee of the Commonwealth who is:
(a) at a place outside Australia; and
(b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and
(c) exercising the employee’s function at that place
Engineer who is:
a) a member of Engineers Australia, other than at the grade of student; or
b) a Registered Professional Engineer of Professionals Australia; or
c) registered as an engineer under a law of the Commonwealth, a State or Territory; or
d) registered on the National Engineering Register by Engineers Australia
Finance company officer with 5 or more years of continuous service
Holder of a statutory office not specified in another item in this list
Judge
Justice of the Peace
Magistrate
Marriage celebrant registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961
Master of a court
Member of the Australian Defence Force who is:
a) an officer
b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years
of continuous service
c) a warrant officer within the meaning of that Act
Member of the Australasian Institute of Mining and Metallurgy
Member of the Governance Institute of Australia Ltd
Member of:
a) the Parliament of the Commonwealth
December 2020 Page 24 of 26
b) the Parliament of a State
c) a Territory legislature
d) a local government authority
Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961
Notary public, including a notary public (however described) exercising functions at a place outside
a) the Commonwealth
b) the external Territories of the Commonwealth
Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in
an office providing postal services to the public
Permanent employee of
a) a State or Territory or a State or Territory authority
b) a local government authority
with 5 or more years of continuous service, other than such an employee who is specified in another item of this list
Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is
made
Police officer
Registrar, or Deputy Registrar, of a court
Senior executive employee of a Commonwealth authority
Senior executive employee of a State or Territory
SES employee of the Commonwealth
Sheriff
Sheriff’s officer
Teacher employed on a permanent full-time or part-time basis at a school or tertiary education institution
December 2020 Page 25 of 26
COMMONWEALTH 0
OMBUDSMAN
Permission for another person to act on my behalf
If you wish to permit another person to complain to the Ombudsman on your behalf, and that
person is not your legal guardian or legal representative, you need to give your consent for that
person to communicate with the Ombudsman’s office. To do so, please complete this form and
provide it to Office of the Commonwealth Ombudsman.
I, ....................................................................................................................................
[your name]
Authorise
........................................................................................................................................
[name of authorised person]
........................................................................................................................................
[phone of authorised person]
........................................................................................................................................
[email of authorised person]
to make a report of abuse on my behalf to the Commonwealth Ombudsman and understand
that the Office of the Commonwealth Ombudsman will share my personal information with
them for that purpose.
I understand that
........................................................................................................................................
[name of authorised person]
will receive my personal information from the Commonwealth Ombudsman about my report.
................................................ …….........................................
Date
GPO Box 442, Canberra ACT 2601 ▪ Phone 1300 395 776 ▪ ombudsman.gov.au
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Form 1: OMBUDSMAN Reporting Abuse in Defence Reporting (Public Order and Safety)

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Completed 7 February 2021

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