Outcome of allegation of harm

Email address for copy of form response *

Employing authority details

Name of employing authority *

Address *

Full name of contact person *

Phone number *

Email address *

School details

Name of the prescribed school *

Address *

Full name of contact person *

Phone number *

Email address *

Teacher details

Name of the relevant teacher: *

Address: *

Teacher registration number (QCT): *

Phone number: *

Email address: *

Details of allegation or allegations

Provide detailed information about the particulars of the allegation/s (the facts and circumstances of the allegation or allegations to the extent available): *

Please provide the date the employing authority stopped dealing with the matter: *

Please provide details on the findings made by the employing authority: *

Please provide details on the outcome of the employing authority’s dealing with the allegation and any reasons for the outcome: *

Please provide details on the employing authority’s decision and reasons for the decision: *

Have you made a reportable conduct notification to the Queensland Family and Child Commission (QFCC) in compliance with the Reportable Conduct Scheme? *

YesNo

Please provide your QFCC reference number (if known):

Please provide information pertaining to any notification to the Queensland Family and Child Commission (QFCC) under the Reportable Conduct Scheme: *

If a reporting entity for the Reportable Conduct Scheme receives a report about reportable conduct, the head ofthe reporting entity or a delegate must:

notify the Commission of the report within three business days of the head of the reporting entity ordelegate becoming aware of the allegation
as soon as practicable after becoming aware of the report about a reportable allegation, ensure aninvestigation is conducted and notify the Commission that the investigation is being conducted
provide the Commission with an interim report within 30 business days of becoming aware of the allegationor conviction
provide the Commission with a final report that includes the investigation findings as soon as practicable.

If known, please provide details about any action taken by the QFCC in relation to the notification:

List any other authorities that have been notified:

E.g. Queensland Police Service, Department of Child Safety, Crime and Misconduct Commission.

If known, provide details about any action taken by the authority or authorities:

Contact details of authority or authorities:

Include their phone, email, and address if known.

Further details of teacher

Type of employment:

E.g. permanent, temporary, contract.

Dates of employment, including end date:

Relevant disciplinary history:

Current employment status:

E.g. stood down, suspended, transferred to non-teaching duties, no action taken.

Further information to assist the QCT to determine whether the teacher poses and unacceptable risk of harm to children:

Attachments

Copy of any relevant complaints/referrals to the QFCC: *

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Copy of any relevant complaints/referrals to other agencies: *

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Copy of any completed investigation reports:

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Copy of any relevant policies (e.g. the school’s student protection policy):

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Copy of all evidence gathered:

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This includes but is not limited to names and contact details of all witnesses, including date of birth for any student witnesses; and a statement as to what other evidence is available e.g. computer files, gifts, letters, text messages.

Copies of any additional relevant documents or evidence:

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