SEXUAL ASSAULT & SEXUAL HARASSMENT
INCIDENT DISCLOSURE RECORD AND CHECKLIST
A staff member must complete this form each time they receive a disclosure of sexual assault or sexual harassment.
The form (page 1) assists the University to gather information about the incidence of sexual assault and sexual harassment within the
University community, so that any general trends can be identified and addressed. Page 2 reminds staff of steps they are required to
take if they receive a disclosure.
The form can be completed without including the name and contact details of the person making a disclosure.
Where a person’s name and contact details are included on the form, the information is de-identified when it is used for identifying any
general trends. No information which could identify individuals will be included in reporting on sexual assault and sexual harassment
within the University community.
DISCLOSURE DETAILS
1.
Person making
the disclosure
Name (optional):
Female: Male: Not provided:
Domesti
c student: International student: Study Abroad student:
Staff member:
2.
Date and time of
meeting
3.
Location of
meeting
Location:
Fremantle:
Broome:
Sydney:
4.
When did the
incident occur
Incident occurred within the last 12 months:
Incide
nt occurred more than 12 months ago:
Notes (opti
onal):
5.
Where did the
incident occur
On campus:
Off campus:
Brief descrip
tion of where the incident took place:
6.
Description of
the incident
Sexual harassment:
Sexual assault:
Other:
Brief desc
ription of what happened:
Did the incident involve:
Male:
Female:
Notre D
ame student: Notre Dame staff:
or Other:
Description:
e.g. family member, stranger, etc.
CHECKLIST
7.
Did you determine there to be any immediate risk to the health, safety or
security of any person?
Yes:
No:
If no, go to Question 9
8.
If yes, did you:
a) contact C
ampus Security
Yes: No:
b) contac
t any other required Emergency Services, e.g. police or ambulance
Yes: No:
c)
contact a Notre Dame Respect Officer:
Yes: No:
If ‘no’ to any of these, explain
why:
9.
Where no immediate risk to health, safety or security, did you:
a) Encour
age the person to contact the University’s Counselling Service
Yes: No:
b) Provide a copy of the Policy: Sexual Assault and Harassment
and a copy of
the Procedure: Disclosing Sexual Assault and Sexual Harassment
Yes: No:
c)
Obtain the person’s consent to the Respect Officer contacting them directly
Yes: No:
If ‘no’ to any of these, explain
why:
If ‘yes
’, how did the person
give consent?
10.
Contact details if the person consents to a Respect Officer
contacting them directly
Preferred contact telephone number and contact time:
Email address:
Other (optional):
11.
If consent is not obtained, did you provide the following support and
information:
a) contact details for Respect Officer
Yes: No:
b)
contact details for Counselling Service Yes: No:
c)
a copy of the Policy and Procedure
Yes: No:
d)
Information regarding other internal support services
(Campus Ministry, Study Support etc.)
Yes:
No:
e) information regarding external support and reporting services (including
police, health & emergency services) Yes: No:
f) information regarding formal reporting options (under student or staff
misconduct processes) Yes: No:
g)
for international students, contact details for the
Overseas Student
Ombudsman Yes: No:
If ‘no’ to any of these, explain
why:
Your name:
Signature
: Date:
Please send this form to a Respect Officer in Fremantle, Broome or Sydney within 24 hours of
the disclosure
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome