Language
English (UK)
Safe Ministry Screening Questionnaire
For all staff and volunteers
Please Note: This is a sensitive document that will be stored in a confidential manner accessible only by a limited number of authorised persons.
Personal details
Full Name
*
First Name
Middle Name
Last Name
Previous Name(s)
If applicable
Date of Birth
*
/
Day
/
Month
Year
Date Picker Icon
Age
*
15 or younger
16 or 17
18 or older
Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Phone Number
*
E-mail
*
example@example.com
Do you have any health conditions that we should know about?
List any churches you have attended regularly in the past 3 years
*
Name of Church
Location
When (month/year)
Any positions held
1
2
3
Back
Next
Screening Questions
All staff and volunteers
All staff and volunteers
*
Yes
No
Have you ever been charged with and/or convicted of a criminal offence?
To your knowledge, has there ever been any allegations made against you regarding any abuse of a child, physical abuse or sexual misconduct?
Have you had a history of alcohol abuse or substance abuse (including
prescription, over the counter, recreational or illegal drugs)?
For staff and volunteers 18 and over
For staff and volunteers 18 and over
Yes
No
As an adult (18+ years) have you ever engaged in sexual contact with someone under your care other than your spouse (such as a parishioner, client, patient, student, employee or subordinate)?
As an adult (18+ years) have you ever engaged in use, possession, production or distribution of child abuse material?
As an adult (18+ years) have you ever engaged in sexual contact with a person under the relevant age of consent?
Have you ever had an apprehended violence order, order for protection or the like issued against you as a result of allegations of violence, abuse, likely harm, harassment, stalking, etc?
Has your driver’s licence ever been revoked or suspended?
Have you ever had permission to undertake paid or voluntary work with
children or other vulnerable people refused, suspended or withdrawn in
Australia or any other country?
Has a child or dependent young person in your care ever been removed from your care by relevant authorities?
stop collapse
Back
Next
Working With Children Check (WWCC) number (if required)
WORKING WITH CHILDREN CHECK AND/OR NATIONAL POLICE CHECK
Yes
No
I consent to verification of my WWCC number (if required, 18+ only)
I consent to a National Police Check (for staff only)
CONSENT TO HOLD INFORMATION
*
Yes
I consent to the information contained in this application, including any subsequent pages, to be kept by our church.
I understand that this information will be kept in a confidential file and used only for screening purposes.
DECLARATION
I, {fullName3} sincerely declare that:
*
Yes
The information I have provided in this application is true and correct to the best of my knowledge and belief.
I understand that if I provide false or misleading information or withhold relevant information from this questionnaire, the church leadership may determine that I am unsuitable to serve in any role in the church.
I received, read and agreed to the Code of Conduct
(via this link)
and am willing to uphold it.
I have provided details
(via this link)
of two referees who are over eighteen years of age and able to give a verbal report on my character and suitability for ministry.
Applicant's signature
*
Clear
If applicant is under 18
Name of Parent or Guardian
First Name
Last Name
Parent/Guardian Contact Phone
Please enter a valid phone number.
Parent/Guardian Signature
Clear
uncollapse
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform