Allegation of Sexual Abuse Form

This form is meant to help anyone who wishes to report an incident of abuse by anyone acting in the name of the Church (i.e., a deacon, priest, employee or volunteer of any parish, grade school or high school supported or run by the Diocese of Owensboro). All information that you submit will be given to the Bishop and the Diocesan Review Board. It may have to be given to the local police. You will be contacted by either the Bishop, our Assistance Coordinator, or a member of the Review Board once your report is received and reviewed.

We support your right to report your claim directly to a local law enforcement agency. The Diocese will cooperate fully in any investigation which you initiate.

If you wish to report this incident to us, please complete the following.

(Please print. Attach extra pages if needed or write on back of this form. Feel free to add additional comments or information on the back of this form.)

• Your name: ________________________________________________________
• Address: __________________________________________________________
• City, State, and Zip Code: ______________________________________________
• Home telephone number: _______________________________________________

Are you the alleged victim? _____________________________________________

If no, what is your relationship to the alleged victim? ___________________________

What is the alleged victim’s name? ________________________________________

How old was the alleged victim at the time of the incident? ______________________

How old is the alleged victim now? _______________________________________

When did the incident occur? ___________________________________________

Where did the incident occur? __________________________________________

Is the alleged victim willing to be interviewed about this incident? _________________

If yes, when and where? ______________________________________________

If no, why not? _____________________________________________________

Is the alleged abuser:

____ A priest?

____ A deacon?

____ An employee of a parish?

____ A Catholic school employee?

____ Other? (Please specify: _____________________________________)

The name of the person being accused is: _______________________________________

OR I prefer to tell the name of the alleged abuser to:

____ the Bishop

____ a member of the Review Board (specify male or female if desired).

____ Please call me at the above telephone number or at (____)____________.

• __________________________________                ________________________
• Your signature                                                         Today’s date
• 
  

Please mail or deliver this form to:

Bishop John J. McRaith

Catholic Pastoral Center

600 Locust Street

Owensboro, KY 42301

You may also call the Bishop at (270) 683-1545 to report this information.