Feedback & Complaints

Feedback Form

Please fill-up the form below:

1. Provider Details:

Report Completed by

Outlet Name

Registration Group

2. Primary Contact Person
Who is the provider’s primary contact for this incident or allegation?

Title

First Name

Last Name

Position at provider

Phone Number

Email Address

Preferred method of contact

3. Incident Category:
The categories of incidents are defined in 73Z of the National Disability Insurance Scheme Act 2013 (Cth) and section 16 of the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018. You may wish to include a secondary category if the incident/allegation falls into multiple categories.

Primary Category

Secondary Category

If the incident is a death, was it anticipated?

Yes No Unknown

4. Incident Details:
If you have completed an internal incident report please provide it to the NDIS Commission with this report.

Incident Location

Location Type

Residential address In the community Specialist disability accommodation Service outlet Other (please type details)

Time of incident/allegation

Date of incident/allegation

If date unknown, reason why

Time the NDIS provider became aware of incident

Date & time NDIS provider became aware of incident

Describe the incident/allegation

What were the circumstances leading up to the incident/allegation?

5. Impacted Person:

Title

First and last name

NDIS participant number

Gender

Date of birth

Primary disability

Other disability

Does the person have any behaviours of concern?

How does the person communicate?

Phone number

Email address

6. Subject(s) of Allegation:
A subject of allegation is a person who has been accused of a reportable incident. A subject of allegation may be a worker within your organisation or another person, for example a resident living in the same house. There may be more than one subject of allegation. If there is not space on this form, please include additional information in an attachment.

Is there a subject of allegation for this incident

Yes No

6.1 Subject of allegation - worker:
Only complete this section if there is a worker who is a subject of allegation.

Title

First Name

Position at time of allegation

Gender

Date of birth

Phone number

6.2 Subject of allegation - person with disability:

Title

First Name

NDIS participant number

Gender

Date of birth

Primary disability

Other disability

Does the person have any behaviours of concern?

How does the person communicate?

Phone number

6.1 Subject of allegation - other:

Title

First name

Relationship to impacted person

Gender

Date of birth

Phone number

7. Immediate Action Taken:

Have the police been informed?

Yes No

Officer's name

Police station

Police event number

If the police have not been informed, why not?

Are the impacted person’s family or guardian aware of the incident?

Yes No, please state why by typing into this box Unsure

If the impacted person is under 18, has the relevant child protection agency been contacted?

Yes No, please state why by typing into this box Unknown Not applicable

7.1 Impacted Person:
If the incident category is death of a person with disability, this section does not need to be completed.

Describe any immediate support that has been offered/provided to the person with disability impacted by the incident (for example, medical treatment, counselling, access to advocacy, removed source of harm)

7.3 Subject of allegation - person with disability:
This only needs to be completed if there is a person with disability who is a subject of allegation.

Describe any immediate action that has been taken or commenced in respect to the person with disability who is the subject of the allegation (for example, review of staffing, review of behaviour support needs, medical review, assistance to access support person or advocate)

8. Risk Assessment:
If you have completed a risk assessment please provide it to the NDIS Commission with this report.

Have you undertaken a risk assessment?

Yes No

If yes, date risk assessment was complete

Details of risk assessment

If no risk assessment has been undertaken, what is the reason for not undertaking a risk assessement?

If you have a risk assessment in progress, when was it started?

When do you expect to be finished?

9. Attachments:
Please upload all supporting documents you need to submit to the NDIS Commission here.

File Attachments

10. Declaration:

I declare that:

I am duly authorised by the organisation identified in this form to submit this reportable incident notification.
I understand that this information is being collected by the NDIS Quality and Safeguards Commission (NDIS Commission) for the purposes outlined in National Disability Insurance Scheme Act 2013 and the NDIS (Incident Management and Reportable Incidents) Rules 2018.
To the best of my knowledge, the information provided in this application is true, correct and accurate.
I acknowledge that the giving of false or misleading information to the Commonwealth is a serious offence under section 137.1 of the schedule to the Criminal Code Act 1995. I understand I need to submit another notification about this incident to the NDIS Commission within 5 business days.

Full Name

Position at organisation

Date

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