GBV Staff Referral Form - Student Wellbeing Portal

University of Sydney Student Wellbeing

Gender-based Violence and Other Harmful Behaviour Reporting Form

This form is for University of Sydney staff and affiliates to report gender-based violence, sexual harm or other harmful behaviours. You can use this form to share your own experience, report another person's experience, or report on behalf of a business unit.

Gender-based violence is physical or non-physical violence, harassment, abuse or threats, based on gender (including sex, gender, gender identity and gender expression), that results in, or is likely to result in harm, coercion, control, fear or deprivation of liberty or autonomy.

The University acknowledges that submitting a report of gender-based violence, sexual harm or other harmful behaviour can be a confronting experience for most people. The Safer Communities Office staff are available 9am to 5pm Monday to Friday, Sydney local time. You can speak with a team member or make an appointment on the phone by calling +61 2 8627 6808 or emailing safer-communities.officer@sydney.edu.au.

If you provide your contact details, the Safer Communities Office can contact you to discuss your needs, offer confidential support and explore available options with you. Any personal information you have provided will be highly protected and kept in accordance with our Privacy Policy 2017. Where possible, the University will also take appropriate action in response to the incident.

The University has a mental wellbeing support line. If you’re in Australia, you can contact the support line by calling 1300 474 065 or by texting 0488 884 429 outside of office hours (5 pm to 9 am weekdays, 24/7 weekends and public holidays).

For counselling support after-hours, please contact FullStop Australia by calling 1800 424 017. FullStop is a free and confidential service available 24 hours a day, 7 days a week to support people impacted by domestic, family or sexual violence.

Whose experience are you reporting?

I am reporting my own experience.
I am reporting someone else's experience (as a witness/bystander, or disclosed to me in a personal capacity).
I am reporting in a professional capacity as a University staff member, affiliate organisation or third party.

I am a:

University of Sydney staff member
Student accommodation staff member
Affiliated or third-party provider staff member
Other member of the University community (i.e. non-staff)

I am a:

Student
Member of the public

I am:

Under 18
18 and above

In certain circumstances we are required by law to report incidents involving children and young people to the NSW Department of Communities and Justice. For further information on this mandatory reporting requirement, please see: Protecting our kids - Mandatory reporters

You can choose to provide your details or submit an anonymous report.

Providing your details allows the Safer Communities Office to contact you, offer confidential support and discuss available options. If you do not provide your details, the University will be unable to contact you.

I wish to provide my contact details.
I do not wish to provide my contact details.

Preferred name:

Last name

Staff ID (optional):

Phone number:

Email address:

Preferred method of contact

Phone
Email

Different term:

I am a:

University of Sydney staff member
Student accommodation staff member
Affiliated or third-party provider staff member
Other member of the University community (i.e. non-staff)

I am a:

Student
Member of the public

You can choose to provide your details or submit anonymously.

Providing your details allows the Safer Communities Office to contact you, offer confidential support and discuss available options. If you do not provide your details, the University will be unable to contact you.

Your full name:

Your University email address:

Your email address:

Your best contact number:

I wish to disclose anonymously.

Please provide details:

Please confirm the team you are reporting on behalf of.

Referring an incident from another team in Student Wellbeing
Reporting an incident on behalf of a University-owned and operated/third-party operated accommodation provider
Reporting an incident on behalf of Campus Security
Reporting an incident on behalf of another University business area
Other

Please provide specific details:

Please provide your details below.

Your full name:

Your work email address:

Your best contact number:

Your Internal Reference Number (if applicable):

Is this a disclosure or a complaint?

Disclosure
Complaint

Your Internal Referral ID (i.e. system reference number):

Is this a referral or a consult?

Referral (consent for SCO support)
Consult (no consent for SCO support)

For the University to provide support and take any other appropriate action, we require the affected person's contact details. Please ensure you have the affected person's consent to share their information.

Has the affected person consented to having their personal details shared?

Yes
No

First name of the affected person:

Last name of the affected person:

Phone number:

Email address:

Preferred contact method:

Phone
Email

Has the affected person consented to being contacted by the Safer Communities Office for specialist support?

Yes
No

Please provide details:

How old is the person affected?

Under 18
18 and above
Unknown

To the best of your knowledge, which of the following describes the affected person's gender identity?

Man or male
Woman or female
Non-binary
Different term
Unknown
Do not wish to disclose

To the best of your knowledge, which of the following describes the affected person's background? You can select more than one if applicable.

Aboriginal and/or Torres Strait Islander
Culturally and linguistically diverse
Diverse sexual orientation or gender identity
A person with disability
None of the above
Prefer not to say

Please provide details:

A reminder: forensic medical examinations for evidence collection can be undertaken up to five days after an incident of sexual assault.
Your local sexual assault service is available 24/7 and can be contacted here.

Date of the incident or most recent incident?

If unknown:

Unknown

Date of the incident or most recent incident?

If unknown:

Unknown

Did this incident occur once, or were there multiple incidents?

Single incident
Multiple incidents

Is it an ongoing situation?

Ongoing
Not ongoing

Did this incident occur once, or were there multiple incidents?

Single incident
Multiple incidents
Unknown

Is it an ongoing situation?

Ongoing
Not ongoing
Unknown

Please provide details:

Please provide details (i.e. accommodation facility and location):

Please provide details:

Please provide details (i.e. accommodation facility and location):

Please provide a description of what happened. You can provide as much or as little information as you feel comfortable sharing.

Please provide a description of what happened:

Were there any other affected persons (including bystanders/witnesses)?

Yes
No

Were there any other affected persons (including bystanders/witnesses)?

Yes
No
Unknown

Have the other affected persons provided consent for their details to be shared?

Yes
No

First name:

Last name:

Email/phone number:

First Name:

Last Name:

Email/phone number:

Please provide details:

Please provide any other identifying information about the person/s responsible:

Privacy collection notice

The University of Sydney's Safer Communities Office and Student Wellbeing will use the information you provide on this form to provide the appropriate support and response to the incident you are reporting.

Any personal information you give us will be highly protected, secured and disposed of in accordance with our Privacy Policy 2017, University’s Cyber Security Policy 2019 and the University’s obligations under the State Records Act 1998 (NSW). We will not share personal information about you or anyone named in your report unless the person has consented, we are required by law to do so (such as the NSW Police), or there is a serious or ongoing risk of harm to the health or safety of any person. To ensure our compliance with the National Higher Education Code to Prevent and Respond to Gender-based Violence, strictly de-identified information about the incident you are reporting may be used in analysis and reporting.

For more information about how the University handles personal information, how individuals can request to access or correct the personal information we hold about them, and who to contact if they have a privacy enquiry or complaint, please see our webpage: Privacy at the University - The University of Sydney.

You have reached the end of this form. Thank you for taking the time to complete it. Once you click the Submit button below, your form will be sent to the Safer Communities Office who will contact you within 2 business days. If you have chosen to submit an anonymous report, we will have no means to contact you.

To amend or withdraw your form after it has been submitted, please contact the Safer Communities Office on +61 2 8627 6808 or at safer-communities.officer@sydney.edu.au