Residential Colleges and affiliated accommodation providers

University of Sydney Student Wellbeing

Gender-based Violence reporting form

Residential Colleges and affiliated student accommodation providers

This information is requested and provided pursuant to the agreement between the University of Sydney and the Residential College or affiliated student accommodation provider to comply with Standard 7 of the National Higher Education Code to Prevent and Respond to Gender-based Violence.

Information will be stored securely in accordance with the University’s Cyber Security Policy 2019 and will be disposed in accordance with the University’s obligations under the State Records Act 1998 (NSW).

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.

Reported Incident Type

Provider type:

Residential College
Affiliated student accommodation provider

Select College from dropdown list:

Please select your location:

Haymarket
Rosebery
Waterloo
Zetland

Please select your location:

Darling House
Darlington (University of Sydney)
Redfern
Quay (Haymarket)

Are you referring or reporting the case to the University?

Referring to the Safer Communities Office for support (with the student's consent).
Referring the case at the student's request, for the University to lead the response.
Escalating to the University due to identified risk to the safety and wellbeing of students and/or staff.
Reporting details of the case, which is being managed locally and does not currently present a risk to the safety and wellbeing of students and/or staff of the accommodation provider.

Please provide your contact details below.

Name:

Contact number:

Email address:

System case ID:

Affected Person's Details

For the University to take action, we require the affected person's contact information.
Please ensure you have their consent to share personal details and for the University to contact them.

Please ensure the affected person is aware that the matter has been referred to the University and that they may be contacted as part of the University's response. They will also have the opportunity to discuss available support and options if they wish.

The affected person has provided consent to share their information.

Yes
No

First name:

Last name:

Phone number:

Email address:

Preferred contact method:

Phone
Email

The affected person has provided consent for the Safer Communities Office to contact them and provide support.

Yes
No

Is the affected person affiliated with the University?

Yes
No
Unknown

Please provide details:

Student ID (if known):

Staff ID (if known):

Please provide details:

Please provide the name of the student accommodation provider:

Name of Reporter's institution (if known):

How old is the affected person?

Under 18
18 and above
Unknown

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 refer to the following pages:

Mandatory reporters - Department of Communities and Justice

Child Safety - University of Sydney

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

Reported Incident Details

Please provide details:

Date of the incident or most recent incident?

If date is unknown:

Unknown

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:

Did the reported incident involve a resident or staff member of another student accommodation provider?

Yes
No
Unknown
Prefer not to disclose

Please provide the name of the other student accommodation provider:

Please provide details:

Please describe what was disclosed to you. The team may reach out to clarify details.

Other affected residents

Were any other residents affected by this incident (including witnesses and bystanders)?

Yes - 1
Yes - 2
Yes - 3+
No

Have any residents requested additional support from the Safer Communities Office and provided consent for their details to be shared?

Yes
No

First name

Surname

Phone number

Preferred mode of contact:

Phone
Email

First name

Surname

Phone number

Preferred mode of contact:

Phone
Email

First name

Surname

Phone number

Preferred mode of contact:

Phone
Email

Risk assessment

Please provide details of the incident risk assessment, including any key risks and actions taken:

Was an immediate safety response required?

Yes
No

Was a safety plan implemented?

Yes - interim
Yes - ongoing
No

Please provide details:

Person/s responsible

Please provide identifying information about every person responsible, if known:

Privacy Collection Notice

Thank you for completing this form. Please submit your report via the button below.

The Safer Communities Office will contact you if any further information or action is required.

Gender-based Violence reporting form

Details of person responsible

Details of second person responsible

Details of third person responsible

Details of fourth person responsible