Safe Ministry Screening Questionnaire (Over 18)

Safe Ministry Screening Questionnaire (Over 18)

Safe Ministry Screening Questionnaire (Over 18)

For staff and volunteers aged 18 and over Please Note: This is a sensitive document that must be stored in a confidential manner accessible only by a limited number of authorised persons.

PERSONAL DETAILS 

Your Name(Required)
Previous Name/s (if applicable):
Sex(Required)
Your Address(Required)
Your Email Address(Required)

Please select 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 Lead Pastors 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 church may need to report this information to the police or other relevant government authorities.

For all staff and volunteers

1. Have you ever been charged with and/or convicted of a criminal offence?(Required)
2a. 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)?(Required)
b. As an adult (18+ years) have you ever engaged in use, possession, production or distribution of child abuse material?(Required)
c. As an adult (18+ years) have you ever engaged in sexual contact with a person under the relevant age of consent?(Required)
3. To your knowledge, has there ever been any allegations made against you regarding any abuse of a child, physical abuse or sexual misconduct?(Required)
4. 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?(Required)
5. Have you had a history of alcohol abuse or substance abuse (including prescription, over-the-counter, recreational or illegal drugs)?(Required)
6. (if the ministry role may involve driving) Has your driver’s licence ever been revoked or suspended?(Required)

For staff and volunteers in pastoral ministry, leadership or engaged in child-related work or work with vulnerable adults

7. 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ever had permission to undertake paid or voluntary work with children or other vulnerable people refused, suspended or withdrawn in Australia or any other country?(Required)
8. Has a child or dependent young person in your care ever been removed from your care by relevant authorities?(Required)

CHURCHES YOU HAVE ATTENDED REGULARLY IN THE PAST 3 YEARS

List
Name of church 
Location
When (Month/Year)
Any positions held 
 

REFEREES

Please 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 part of the church.
Name(Required)
Name(Required)

WORKING WITH CHILDREN CHECK AND/OR NATIONAL POLICE CHECK

I consent to: * verification of my WWCC number (in NSW, if required) * a National Police Check (for staff only)

CONSENT TO HOLD INFORMATION

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 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 church leadership 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. 
Clear Signature
DD slash MM slash YYYY
This field is for validation purposes and should be left unchanged.