7.
Did you determine there to be any immediate risk to the health, safety or
security of any person?
☐
☐
If no, go to Question 9
8.
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
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