Safe Ministry Screening Questionnaire

1
Name
First Name
Last Name
2
Previous Name/s (if applicable)
3
Date of Birth
Date
Year
Month
Day
4
Gender
Male
Female
5
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number
Please enter a valid phone number.
7
Email
example@example.com
8
WWCC / WWVP NumberIf required
9
Do you have any health concerns we should know about?
Huge
Large
Normal
Small
Ok
Ok
10
Please indicate either “YES” or “NO” for each of the following questions. If you answer “yes” to any of the following questions, please give details on a separate page or discuss with the Senior Pastor or the person holding an equivalent leadership role in your church. A ‘yes’ answer will not automatically rule an applicant out of selection.
Please note that, if you disclose any potentially criminal actions, the Baptist Association may need to report this information to the police or other relevant government authorities.
11
1. Have you ever been charged with and/or convicted of a criminal offence?
YESNO
12
2(a). 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)
YESNO
13
2(b).As an adult (18+ years) have you ever engaged in the use, possession, production or distribution of child abuse material?
YESNO
14
2(c). As an adult (18+ years) have you ever engaged in sexual contact with a person under the relevant age of consent?
YESNO
15
3. To your knowledge, has there ever been any allegations madeagainst you regarding any abuse of a child, physical abuse or sexualmisconduct?
YESNO
16
4. Have you ever had an apprehended violence order, order forprotection or the like issued against you as a result of allegations ofviolence, abuse, likely harm, harassment, stalking, etc?
YESNO
17
5. Have you had a history of alcohol abuse or substance abuse(including prescription, over-the-counter, recreational or illegaldrugs)?
YESNO
18
6. (if the ministry role may involve driving) Has your driver's licence ever been revoked or suspended?
YESNO
19
Have you ever had permission to undertake paid or voluntary workwith children or other vulnerable people refused, suspended orwithdrawn in Australia or any other country?
YESNO
20
Has a child or dependent young person in your care ever beenremoved from your care by relevant authorities?
YESNO
21
CHURCHES YOU HAVE ATTENDED REGULARLY IN THE PAST 3 YEARS
Name of Church
Location
When (month / year)
Any positions held
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
1
2
3
Name of Church
Row 0, Column 0
Location
Row 0, Column 1
When (month / year)
Row 0, Column 2
Any positions held
Row 0, Column 3
Name of Church
Row 1, Column 0
Location
Row 1, Column 1
When (month / year)
Row 1, Column 2
Any positions held
Row 1, Column 3
Name of Church
Row 2, Column 0
Location
Row 2, Column 1
When (month / year)
Row 2, Column 2
Any positions held
Row 2, Column 3
1 of 3
22
REFEREESPlease provide details of two referees who are over eighteen years of age and able to give a verbal report on your character and suitability for ministry. Referees may be a part of the church.
Full name
Phone
Referee 1
Row 0, Column 0
Row 0, Column 1
Referee 2
Row 1, Column 0
Row 1, Column 1
Referee 1
Referee 2
Full name
Row 0, Column 0
Phone
Row 0, Column 1
Full name
Row 1, Column 0
Phone
Row 1, Column 1
1 of 2
23
CONSENT TO HOLD INFORMATION
I consent to the information contained in this application, including any subsequent pages, to
be kept by the Baptist Association. I understand that this information will be kept in a
confidential file and used only for screening purposes.

DECLARATION
I, First Name Last Name sincerely declare that:
• 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 Baptist Association may determine that I am
unsuitable to serve in any role in the church.
• I have received a copy of the Code of Conduct and am willing to uphold it.

Applicant's signature: Signature Date: Date
24
CHURCH USE ONLY

CSS Training undertaken:    Date of training
WWCC No. supplied:    Yes     No Expiry date: Date
WWCC verified by:    First Name     Last Name     On: Date
Signed Code of Conduct received by:    First Name     Last Name     On:    Date
Entered onto Safe Church Register by:    First Name     Last Name     On:    Date
Interview led by:    First Name     Last Name     On:    Date
Referee Checks conducted by:    First Name     Last Name     On:    Date
Volunteer Endorsement* by:    First Name     Last Name     On:    Date
Induction led by:    First Name     Last Name     On:    Date
*Volunteers must be endorsed by a member of pastoral staff, governance group or safe church team.

Full records of the above processes (including interview notes, referee check comments and induction content) should be kept in the relevant staff and volunteer admin file.
Should be Empty: