Information Sharing Request

Name and Position of Requester:

Date of Request(Required)

Email(Required)

Phone

Agency Name:

Is the Agency a:(Required)

Risk Assessment Entity (RAE)

Information Sharing Entity (ISE)

Both

Details of Request

Who is the subject of the request?(Required)

An alleged perpetrator (RAEs only)

A perpetrator

An adult victim survivor (no child at risk)

An adult victim survivor (child at risk)

A child victim survivor

Details (name/DOB/address/contact number) if known:

Has consent been obtained from the adult victim survivor?(Required)

Yes

Verbal Consent Date/Time:

Signature (if obtained)

Upload scan/photo of signature

Max. file size: 20 MB.

If consent was not obtained, provide a statement explaining the reasons why consent was not sought and obtained

What is the purpose of the request?

Family Violence Assessment (RAEs only)

Family Violence Protection

What information are you requesting?(Required)

(Please indicate the specific information you are requesting, the reason why it is needed, including any risk factors or circumstances indicating the urgency of the request)

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Information Sharing Request

Details of Request

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