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Home > Current students > Safety and wellbeing > Safety and Wellbeing Portal Form

Safety and Wellbeing Portal Form

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All reports are individually and sensitively addressed for further action. You may choose to identify yourself * as the submitter of this report and understand that Wentworth Institute of Higher Education may contact you to follow-up, discuss, and/or act further. You can choose not to be identified or contacted if you wish.

* The contents of all submitted reports, including the submitter’s identity and contact details where supplied, are handled confidentially according to Wentworth Institute of Higher Education’s Privacy Policy.

Incident Report

Q1. Date of submission*

DD dash MM dash YYYY

(today’s date)

Q2. Are you reporting for yourself or for someone else?*

Myself

Someone else

Q3. Are you (or the person on whose behalf you are reporting) under 18 years old?*

Yes

No

Q4. How are you (or the person on whose behalf you are reporting) connected to Wentworth Institute of Higher Education (WIN Education)?*

Student (Undergraduate)

Student (Postgraduate)

Staff Member

Visitor

Other/None of the above

Q4 - None Above*

please specify

Q5. How is the person who you believe committed the unwanted behaviour connected to the person who experienced this unwanted behaviour?*

Fellow student

Friend

Partner or ex-partner

Lecturer or staff member

Family member

Stranger

Other/None of the above

Q5 - None Above*

please specify

Q6. Where did this experience occur?*

On Campus

Off Campus

Q7. Please indicate if you believe any of the following factors contributed to the incident.*

Check all that apply.

Race, ethnicity, and/or nationality

Sex, gender, and/or gender identity

Religion and/or personal beliefs

Sexuality

Disability

Age

Other/None of the above

Unknown/not sure

Q7-None Above

please specify

Q8. Please indicate if you believe the incident fits into any of the following categories.*

You may select any/all that apply.

Sexual assault/sexual harassment

Non-sexual assault/harassment

Bullying

Other discrimination

Other

Q8 - Other*

please specify

Q9. Please provide the date and time when the incident occurred. If you're unsure, please provide your best estimate.*

Q10. Please describe what happened during the incident.*

Your Information

Q11. Do you wish to provide your name with this report?*

If you choose not to provide your name or contact details, please note that we may not be able to follow up on your submission. However, rest assured that all reports will be handled confidentially and sensitively, and appropriate action will be taken as necessary. Should you later decide to share your information, you can do so using this form or by emailing us at [email protected].

Yes

No

Name*

First Last

WIN Student ID

(if you are a student at WIN):

Please provide a safe email address and/or phone number where we can reach you to discuss your report. This does not have to be your WIN Email address. You can choose to provide the phone number of a trusted friend or relative. You're not required to provide both an email address and phone number. However, please ensure you provide at least one, so we can contact you.

12a) Email address*

Please format as email input field with required attribute(s) for validation, e.g., the submitter must input a properly formatted email address (userID+@+domainname), to avoid input errors.

Enter Email Confirm Email

12b) Phone number*

Can we safely call you on this number?*

Yes

No

12c) Please tell us if you have any preferences or restrictions for contacting you.

(e.g., "do not leave a voicemail," "do not text," "only call during specific hours").

12d) Do you have any other special circumstances?

12e) Do you have any additional comments or concerns? Is there anything else you would like to share with us?

Review Information and Submit

{all_fields}

Click to proceed*

I confirm that the information provided in this report is true and accurate to the best of my knowledge.

Go back before submitting if you need to change any information, or submit your report now.

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