C3HB Safe Church Screening SC019

Screening to be completed by all team (volunteers or paid) including board members.

Personal Details

First Name *

Middle Names

Last Name *

Previous Names

Address

Email *

Contact Number *

Date of Birth

Marital Status

Privacy Statement

Any personal information you provide is protected under the Privacy Act 1988 and collected by C3 Church Henley Beach Inc. for the purpose of your involvement. It will be kept in a confidential file and used in implementing our church policies and procedures.

It will be kept in a confidential file and used in implementing our church policies and procedures. It can only be disclosed to someone else if you have been given reasonable notice of the disclosure; where disclosure is authorised or required by law or is reasonably necessary for the enforcement of the criminal law; if it will prevent or lessen a serious and imminent threat to a person’s life or health; or if you have consented to the disclosure.

Screening Questions -- Please answer Yes or No. If Yes, provide detail.

1. Have you made any unsuccessful applications for a leadership role at a church prior to this application? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

2. Have you ever, since age 18, been known by any name other than the one given above (other than maiden name)? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

3. Have you done anything likely to adversely affect your reputation that might affect your fitness to serve? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

4. Is there any information from your past or present that may result in allegations of abuse, harassment, or assault? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

5. Have you ever been the subject of an investigation by police, child protection, employer or other authority? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

6. Have you ever had an accreditation to work with children refused, suspended or withdrawn? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

7. Has a child in your care ever been removed from your care or been the subject of a child protection risk assessment? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

8. Has disciplinary action ever been taken against you by a licensing board, professional association, employer or church? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

9. Are there complaints pending against you before any of the bodies referred to in Question 8? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

10. Have you ever been asked to resign or had employment terminated by a voluntary association, employer or church? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

11. Have you ever had a civil suit brought against you arising out of alleged professional misconduct? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

12. Have you ever been charged and/or convicted of a criminal offence? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

Sexual misconduct includes:

• abuse of power or role for sexual purposes,

• not only sexual intercourse but also intentional touching and sexual conversation of any kind with a person in a

pastoral or professional relationship (e.g. client, patient, employee, student, subordinate, congregation member),

• not only sexual intercourse but also intentional touching and sexual conversation of any kind with a person

under the age of consent or an adult incompetent to give consent,

• sexual assault (e.g., rape),

• soliciting for sexual purposes,

• an oﬀence related to pornography or public indecency (e.g, indecent exposure).

Sexual harassment includes but is not limited to:

• Unwelcome sexual advances or requests for sexual favours

• Directly oﬀensive verbal comments or innuendo of a sexual nature

• Oﬀensive gestures

• Comments regarding a person’s sexual orientation or sexual appeal

13. Have you ever been accused of, or engaged in, sexual misconduct or sexual harassment? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

14. Have you ever been charged with possession, production, or distribution of pornographic materials? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

16. Have you ever been charged with an offence under taxation or other revenue laws? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

17. Has your driver's licence ever been revoked or suspended? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

18. Have you ever had a Personal Protection Order, Domestic Violence Order or similar order issued against you? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

19. Have you ever had a licence to own firearms refused or revoked? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

20. Since your conversion, have you ever participated in any occult practice? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

21. Does your consumption of alcohol impact your relationships or ability to work? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

22. Have you ever used any prohibited drug or misused prescription drugs? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

23. Have you ever had a problem with gambling? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

25. Is there any information that may result in allegations of sexual conduct inconsistent with Christian standards? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

26. Have you ever been unfaithful in marriage? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

27. Have you ever had a bankruptcy order or composition with creditors made against you? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

28. Have you ever been the subject of a complaint about a breach of confidentiality? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

29. Have you done anything that may result in allegations of bullying or harassment of adults? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

30. Is there anything in your background not disclosed, which if public could adversely affect your good name? (Yes / No — if Yes, provide detail)

Tip: Please answer Yes or No. Provide detail if Yes.

Background Check: Christian Ministry

Include every church you have attended regularly since turning 18: where applicable

Church 1 — Name, Role/Position, Location, Start + End Date

Church 2 — Name, Role/Position, Location, Start + End Date

Church 3 — Name, Role/Position, Location, Start + End Date

Referees

Please supply the NAME, ADDRESS and EMAIL of two referees over the age of 18. Include a referee from your last church if you have lived in another state or country. This can be a House Party Leader ( small group leader ), team leader or pastor ect. The purpose of the referee is for Australian Complians purposes.

Referee — Title

Referee 1 — First Name *

Referee 1 — Last Name *

Referee 1 — Email *

Referee 2 — Title

Referee 2 - First Name *

Referee 2 - Last Name *

Referee 2 - Email *

Declaration

I sincerely declare that: the information I have provided is true and correct; I have received a copy of the Code of Conduct and agree to adhere to it; I understand that any material misstatement may render me unfit to hold a position; there is nothing in my background undisclosed that could adversely affect my good name; I consent to the collecting, using and disclosing of personal information as described in the Privacy Statement.

Full Name (signature) *

Date *