Online Safety Commission Complaint Form Lead Source -None- Email Face to Face Phone Website 1. First Name * 2. Last Name * 3. Address * 4. Gender * -None- Male Female Other 5. Age 6. Phone Contact 7. Email 8. Employment Status -None- Employed Unemployed Student 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 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) Captcha validation failed. If you are not a robot then please try again.
