Incident Information Form

A safe disclosure process

This form may ask for information that is difficult for you to share. If at any time you feel that things are getting a bit hard for you it’s okay for you to stop completing the form and contact Adsafe on the numbers below to talk through the information you would like to share, you may find that this turns out to be an easier option for you.

AUS: 1800 220 468 or NZ: 0800 442 458

Immediate Danger

If you believe a child is in immediate danger or at risk of serious harm contact the police and/or the local child protection agency immediately.

Anonymous Completion

Adsafe respects your right to complete this form anonymously. However, so that we can best ensure the protection of children and vulnerable people in our church and its entities, we encourage you to provide us with some basic details such as your first name and best contact method just in case we need to contact you to clarify anything.

Unknown Information

This Incident Information form may ask for information you do not have, that's okay. For these questions, please leave blank or write "not known". However, the more information you can share with Adsafe the better our ability to ensure the best outcome for all involved.

Privacy Statement

Confidentiality and your privacy is very important to Adsafe. The way we handle your personal information is outlined in our Privacy Policy which can be viewed here.

Adsafe may be required to report the information you provide us to the police or other government agencies. The specific way we use the personal information you provide is covered by the Disclosure Collection Notice which you can view here.

Section A

Personal Details

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(If Yes, please contact the police and/or your local child protection agency immediately)

Section B

If at any time you feel that things are getting a bit hard for you it's okay for you to stop completing the form and contact Adsafe on the numbers below to talk through the information you would like to share, you may find that this turns out to be an easier option for you.

AUS: 1800 220 468 or NZ: 0800 442 458

Victim / Survivor Details

(If same as above, go to Section C)

Section C

Please complete as much as possible and if you are not aware of some of the details please leave them blank, however the more information you can share with us the better our ability to ensure the best outcome for all involved.

If at any time you feel that things are getting a bit hard for you it's okay for you to stop completing the form and contact Adsafe to talk through what you would like to share, this may be an easier option for you.

AUS: 1800 220 468 or NZ: 0800 442 458

Person Subject of Allegation (PSOA) Details

Employment Position or Volunteer Role and Church attending at time of the alleged offending

Section D

Please complete as much as possible and if you are not aware of some of the details please leave them blank, however the more information you can share with us the better our ability to ensure the best outcome for all involved.

Information about the alleged incident

When and where did this incident occur? (i.e. name of church, school, city, state etc.)

Witnesses or people aware of the incident/s

Information about the alleged incident

Information about the alleged incident

What happens next

Once Adsafe has received your Incident Information Form, we will review the information you have given us to determine what the next steps to ensure the safety of children and/or vulnerable people in our church and its entities. We may need to talk to you to clarify some information and we will do this by the preferred contact method you have provided in this form.

Thank you for taking the time to share your information with Adsafe.

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