Sex of allegeo offender Male Female Date of Birth or approximate age Was the alleged offender a family member or domestic partner of the viclim?• No Yes If Yes.how are you related to the offender? I am their. .-------------------, son,lather, ste sisrer. former domestic parmttr} (tt.g.wife, This lnfonnallon ls for data collecllon purposes only) If more than two years have lapsed since the act of violence please outline your reasons for not filing an application within this time (f please addtion81 mmeriaJ required. 8lt8Ch if 4. REPORTING DETAILS Has the act of violence been reporteo to the 0 Yes No Police? If yes.please provide the details: Name RegisteredNo Rank Police Station Date of Report If no. you must provide a statutory declaration sett ng out the circumstances of the act of violence and provide the reason for the failure to report the matter to police. 0 Statutory Declarat on attached? Yes No (? Unknown Have criminal proceeoings commenced? Yes No there intervention oroers relating to this matter? Yes No Case number Ate known) (if 0 0 If the incident occurreo in the workplace,was it reporteo to your employer? Yes No 0 0 Has the act of violence been reporteo elsewhere? Yes No tf yes, please provide the details: 5.WHAT EFFECTS HAVE RESULTED FROM THE ACT OF VIOLENCE? 0 Physical• No 0 Yes 0 Psychological• No 0 Yes Grief.Stress or 0 Yes Trauma Prmnde details 0 No 0 If yes.what hospital? Yes No Did you attend a hospital
Sex of allegeo offender Male Female Date of Birth or approximate age Was the alleged offender a family member or domestic partner of the viclim?• Yes No If Yes.how are you related to the offender? I am their. .-------------------, (tt.g.wife, son,lather, ste sisrer. former domestic parmttr} This lnfonnallon ls for data collecllon purposes only) If more than two years have lapsed since the act of violence please outline your reasons for not filing an application within this time (f please 8lt8Ch addtion81 mmeriaJ if required. 4. REPORTING DETAILS Has the act of violence been reporteo to the Police? If yes.please provide the details: Yes 0 No Name RegisteredNo Rank Police Station Date of Report If no. you must provide a statutory declaration sett ng out the circumstances of the act of violence and provide the reason for the failure to report the matter to police. Statutory Declarat on attached? (? Yes 0 No Have criminal proceeoings commenced? Yes No Unknown Ate there intervention oroers relating to this matter? Yes No Case number (if known) If the incident occurreo in the workplace,was it reporteo to your employer? Yes 0 No 0 Has the act of violence been reporteo elsewhere? Yes 0 No 0 tf yes, please provide the details: 5.WHAT EFFECTS HAVE RESULTED FROM THE ACT OF VIOLENCE? Physical• Psychological• Grief.Stress or Trauma Prmnde details Yes 0 Yes 0 Yes 0 No 0 No 0 No 0 Did you attend a hospital If yes.what hospital? Yes No 0
VLRC_Victims_of_Crime_Assistance_Act_Supplementary_Consultation_Paper.docx