Reportable Conduct Scheme
Notification
Form: Three-day notification (heads of entity/Department delegates)
The following eform will meet the requirement for the mandatory 3 day notification by heads
of entity. The form will allow you to preview and print the information before you submit.
Once you submit the information, you will be given a reference number and token which will
be required for subsequent updates. The reference number and token will also be emailed to
you.
Details of person submitting this form
1.
2.
3.
4.
First name
Last name
Phone
Email
Details of your organisation
1.
2.
3.
4.
5.
6.
7.
Organisation name
Address line 1
Address line 2
Town/suburb
State
Postcode
What type of organisation are you?
Details of the allegation(s)
1. Was the allegation(s) reported to you by another person ? (if yes, question 2 below)
a. Yes
b. No
2. When was the allegation(s) reported to you?
3. First name of employee
4. Middle name of employee (if known)
5. Last name of employee
6. Former names or aliases (if known)
7. Is the person over 18 years of age?
a. Yes (if selected, question 8 below)
b. No
8. Employee’s date of birth
9. When did the alleged misconduct occur?
10. Where did the alleged misconduct occur?
a. In the course of employment
b. Outside the course of employment
c. Unknown
11. Allegation type (check boxes)
a. Sexual offence committed against a child
b. Sexual offence committed with a child
c. Sexual offence committed in the presence of a child
d. Sexual misconduct committed against a child
e. Sexual misconduct committed against with a child
f. Sexual misconduct committed in the presence of a child
g. Physical violence committed against a child
h. Physical violence committed with a child
i. Physical violence committed in the presence of a child
j. Behaviour that causes significant emotional or psychological harm to a child
12. Brief summary of allegation
Police report
1. Have you or your organisation reported the matter to police? (if yes, further questions
below)
a. Yes
b. No
2. When was the police report made?
3. What is the police reference number?
4. What police station was the report made to?
Supporting documentation
1. Do you want to attach any supporting documents? (upload button)
Page 2 of 2
p. 1300 782 978
w. ccyp.vic.gov.au
Level 18 / 570 Bourke Street Melbourne, 3000 DX210229