Incident disclosure record and checklist

Sexual assault, sexual harassment & family and domestic violence

This form assists the University in gathering information about the incidence of sexual assault, sexual harassment and family and domestic violence within the University community. Any general trends can be identified and addressed, and the form helps guide staff through the steps they must take if they receive a disclosure.

A staff member must complete this form within 24 hours each time they receive a disclosure of sexual assault, sexual harassment or family and domestic violence. 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 used to identify any general trends. No information which could identify individuals will be included in reporting on sexual assault and sexual harassment within the University community.

For further information about staff reporting obligations, please see the University’s Policy: Sexual Assault and Sexual Harassment and Procedure: Disclosing Sexual Assault and Sexual Harassment, or contact a Respect Officer.


Disclosure Details

Person disclosing an experience of sexual harassment, sexual assault or family and domestic violence

Name (Optional)
 
Gender
 
Campus Location
 
Additional information - tick any that apply *
 
Any other demographic information (if known)
 

When was the disclosure made to you?

 

Where was the disclosure made to you?

Incident Details

When did the incident occur? *
 
Where did the incident occur? *
 
Description of the incident *
 
Type of perpetrator *

Checklist

1. Did you determine there to be any immediate risk to the health, safety or security of any person? *

Where there was immediate risk to health, safety or security, did you:

a. Contact Campus Security
Give the reason why you selected no:
 
 
b. Contact any other required Emergency Services, e.g. police or ambulance
Give the reason why you selected no:
 
 
c. Contact a Notre Dame Respect Officer
Give the reason why you selected no:
   

Where no immediate risk to health, safety or security, did you:

a. Encourage the person to contact the University’s Counselling Service
Give the reason why you selected no:
 
 
b. Provide a copy of the Policy: Sexual Assault and Harassment and a copy of the Procedure: Disclosing Sexual Assault and Sexual Harassment
Give the reason why you selected no:
 
 
2. Obtain the person’s consent to the Respect Officer contacting them directly? *
Give the reason why you selected no:

Contact Details

Preferred Contact Time

If consent is not obtained, did you provide the following support and information:

a. Contact details for Respect Officer
Give the reason why you selected no:
 
b. Contact details for Counselling Service
Give the reason why you selected no:
 
c. A copy of the Policy and Procedure
Give the reason why you selected no:
 
d. Information regarding other internal support services (Chaplaincy, Study Support etc.)
Give the reason why you selected no:
 
e. Information regarding external support and reporting services (including police, health & emergency services)
Give the reason why you selected no:
 
f. Information regarding formal reporting options (under student or staff misconduct processes)
Give the reason why you selected no:
 
g. For international students, contact details for the Overseas Student Ombudsman
Give the reason why you selected no:
 

Reporter Information and Declaration

 

The information provided in this form will only be used for the administrative or educational purposes of the University, or in accordance with your specific consent. The University will not disclose your personal information to a third party unless required to or permitted by law or where you have consented to the disclosure. Information relating to how the University collects, uses or discloses your personal information and how you may complain about the University’s handling of your personal information is contained in the University’s Privacy Policy.
You have a right to access your personal information that the University holds about you and to seek its correction. If you wish to access your personal information or inquire about the handling of your personal information, please contact Student Administration at student.admin@nd.edu.au