Safe Ministry Screening

Safe Ministry Screening Questionnaire

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

For all staff and volunteers

Please select either “YES” or “NO” for each of the following questions. If you answer “yes” to any of these questions, please give details below 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 church may need to report this information to the police or other relevant government authorities.
1. Have you ever been charged with and/or convicted of a criminal offence? YesNo
2. As an adult (18+ years) have you ever engaged in any of the following conduct:
• sexual contact with someone under your care other than your spouse (such as a parishioner, client, patient, student, employee or subordinate) YesNo
• use, possession, production or distribution of child abuse material?YesNo
• sexual contact with a person under the relevant age of consent YesNo
3. To your knowledge, has there ever been any allegations made against you regarding any abuse of a child, physical abuse or sexual misconduct? YesNo
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? YesNo
5. Have you had a history of alcohol abuse or substance abuse (including prescription, over-the-counter, recreational or illegal drugs)? YesNo
6. (if the ministry role may involve driving) Has your driver’s licence ever been revoked or suspended? YesNo

Churches you have attended regularly in the past 3 years

Church One


Church Two


Church Three


Referees

Referee One


Referee Two


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 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.


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