September 2023 - Online Safety Commission Fiji

Online Safety Commission Complaint Form

Lead Source

1. First Name *

2. Last Name *

3. Address *

4. Gender *

5. Age

6. Phone Contact

7. Email

8. Employment Status

9. Occupation

10. School (if student)

11. Other details

12. Relationship to complainant

13. Alleged date of incident

14. Platform/medium used

15.Details of incident and subject electronic comm

16. Alleged person complaint against

17. Contact details of person stated in 16 above

18. Further details of person stated in 16 above

19. Relationship to person stated in 16 above

20. Other parties

Declaration Form

I hereby declare that the information submitted in this form is true and correct to the best of my knowledge.

I understand that the provision of false information to the Online Safety Commission is an offence under the False Information Act 2016 and may result in a fine of up to $10,000 or imprisonment of up to 5 years, or both.

Dated Name of Complainant Signature of Complainant or on behalf

(E-signature will appear here when name is filled in)

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Declaration Form