SAFEGUARDING COMPLAINT AND INCIDENT REPORT FORM

This form can be used to share information about a safeguarding complaint, concerns, incident, disclosure, suspicion or allegation of harm or abuse, relating to a child, young person or adult at risk (vulnerable adult).

We recognise that raising such matters may be difficult, and we thank you for bringing this matter to our attention.

If you are reporting concerns about reportable conduct by a worker of the Diocese of Cairns, please complete the Reportable Conduct Form accessible on our webpage: Safeguarding - Catholic Diocese of Cairns

Part 1 - Privacy

The Diocese of Cairns ("the Diocese") collects, uses and holds personal information in accordance with the Australian Privacy Principles set out in the Privacy Act 1988 (Cth). The information you supply will be handled with care and accessed solely by authorised Diocesan personnel, unless required to be disclosed to Police and relevant authorities as authorised by Law.

You have the option for anonymous reporting. Providing your contact details assists the Diocese in assessing, verifying and responding appropriately to safeguarding concerns. If you choose to remain anonymous, this may limit the Diocese's ability to fully assess and respond effectively to the concerns raised if we are unable to seek clarification or further information.

As you complete the form, if you do not have all the details, please provide as much information as you can.

Part 2 - Your Details

Would you like to share your contact details? *

YesNo (I wish to remain anonymous)

First Name

Last Name

Phone

Any other contact details you would like to provide?

Part 3 - What is the nature of the incident, concern, or disclosure you are reporting?

Does this matter involve: a suspected child sexual offence against a child under 18 years of age; or an adult who is reporting child sexual abuse that occurred when they were a child?

YesNo

How did you become aware of the incident or concern?

The victim/survivor told you (direct disclosure)Another person told you (third party disclosure)You witnessed the incidentOther notification

Did anyone else witness the incident?

YesNoUnknown

Part 4 - Details of the Incident, concern or disclosure

Date of incident(s)

Time of incident(s)

Location of incident(s)

Please describe the event/what happened in as much detail as possible

Have you previously shared these concerns with anyone within the Diocese?

YesNo

Name of the person you informed

Role of the person you informed

Part 5 - Who is the alleged offender/perpetrator/person of concern?

Do you know the name or any details about the person of concern?

YesNo

First Name

Last Name

Gender

MaleFemaleNon BinaryOther

Are there any care or support needs you would like us to know about?

YesNoUnknown

Is the person of concern a parishioner with the Diocese of Cairns?

YesNoUnknown

Is the person of concern aware of the allegation(s)?

YesNoUnknown

Is there more than one alleged offender/perpetrator/person of concern?

YesNoUnknown

Part 6 - Details of the Victim/Survivor

Is the victim/survivor:

A child/young person (<18 years)An adult at risk (vulnerable adult)An adult

First Name

Last Name

Date of Birth

Age at the time of the incident

Gender

MaleFemaleNon BinaryOther

Are there any care or support needs you would like us to know about?

YesNoUnknown

Are you aware if the victim/survivor's parent/guardian/carer has been notified of these concerns?

YesNoUnknown

Is there more than one victim?

YesNo

Is the victim:

A child/young person (<18 years)An adult at risk (vulnerable adult)An adult

First Name

Last Name

Date of Birth

Age when the reportable conduct occurred

Gender

MaleFemaleNon BinaryOther

Are there any care or support needs you would like us to know about?

YesNoUnknown

Are you aware if the victim/survivor's parent/guardian/carer has been notified of these concerns?

YesNoUnknown

Are there more victim/survivor(s)?

YesNo

Part 7 - Other Agencies

Have you reported the concerns to another agency or regulator?

YesNo

Which agency has the concern been referred to?

Reported to Police

Reported to Child Safety

Professional Standards and Safeguarding Office Cairns

Other Agency:

Part 8 - Additional Information

Is there any additional information you would like to provide?

YesNo

Part 9 - Supporting Information: Attachments

Do you have any items that might support this report? (for example photos, videos, screenshots, messages, letters, reports, records)

YesNo

Please do not attach material that may breach legislation such as, intimate images of children or recordings shared without permission.

To assist in a timely assessment of your notification, please provide copies of all relevant records on hand, including any initial statements, incident reports, CCTV footage or other evidence. Maximum individual file size is 5MB. Maximum total file size is 25MB.

If you cannot attach your documents, please email them to safeguarding@cairns.catholic.org.au

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Part 10 - Your Declaration

I make this report in good faith and I confirm the information provided is true and correct to the best of my knowledge. *

I understand the Diocese of Cairns encourages all suspected criminal behaviour to be reported directly to the Police. *

I understand laws in Queensland, require adults to report child sexual offences (current or historical) to the Police, unless there is a reasonable excuse not to do so. *