YOC Compliment/Complaint Record Form

Compliment/Complaint Record Form
Please be assured that all information is strictly confidential.
We encourage you to make your compliment or complaint using this form and will endeavour to respond as soon as possible.

If you feel unsure about anything or would like help to complete this form, please speak to a Staff Member or one of the Management Team.
Please select an option from the list below, who are you?*

AnonymousNDIS ParticipantAdvocateInformal decision makerOther
Personal Details of Person/Participant involved
Person/Participant's Full Name

First NameLast Name
Person/Participant's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person/Participant's Email
example@example.com
Person/Participant's Phone Number

Area CodePhone Number
Person/Participant's Mobile Phone Number
Please enter a valid phone number.
Compliment or Complaint Details
Is this a:*

ComplimentComplaint
Date event occured

YearMonthDay
Date
What happened?
Where it happened?
Who was involved? (list all persons involved amd witnesses if applicable)
Did someone witness the incident? Would they be willing to be contacted regarding your complaint?
If so, provide the name and contact details. (Inform the witness that they may be contacted by Your Own Care to discuss the matter.)
Any other relevant details
Impacts
Describe the impact and how it affects the person/s or participant directly or indirectly.
Complaint specific: Desired outcomes
Outline the desired outcome of the person/s or participant affected by the issues in this complaint.
File upload: Attached any additional notes or documents of any support evidence (if needed)

Cancelof
Contact Details
The information provided below will be used to contanct you. Only provided contact details that you wish to be contacted on.
Contact Person's Full Name (Optional)

First NameLast Name
Contact Person's Email (Optional)
example@example.com
Contact Person's Mobile Phone Number (Optional)
Please enter a valid phone number.
Contact Person's Signature

Clear
Submission Date

YearMonthDay
Date
OR If you choose to remain anonymous
Your Own Care will investigate these events to the best of our ability and will endevour to add improvements as identified to our systems.
PRIVATE & CONFIDENTIAL

Your Own Care Pty Ltd | ABN: 40 634 453 900

Version: 12/09/2022

Management Use Only

Management to fill in below
Date Received

YearMonthDay
Date
Date Acknowledged

YearMonthDay
Date
Date Manager Notified

YearMonthDay
Date
Date Investigation Outcomes Due

YearMonthDay
Date
Date referred to NDIS Commission (if applicable)

YearMonthDay
Date
Relevant dates
Progress Date 1

YearMonthDay
Date
Progress Date 2

YearMonthDay
Date
Progress Date 3

YearMonthDay
Date
Progress Date 4

YearMonthDay
Date
Date Investigation Outcomes Communicated

YearMonthDay
Date
Date Decision review options communicated

YearMonthDay
Date
Date Outcome Appealed

YearMonthDay
Date
Date Complaint Closed out

YearMonthDay
Date
Date Outcomes listed for Management Meetings

YearMonthDay
Date
Compliment/Complaint Details
Was this compliment/complaint formally ACKNOWLEDGED by receipt verbally and electonically?

YesNo
Impacts: Important ALWAYS refer NDIS (Procedures Fairness) Guidelines 2018
Who was impacted by the complaint?

Provision of Service or SupportSpecific Worker (involves procedural fairness)Provision of Service or Supports that incidentally identifies workerOther
Details of Answers provided
Details If not a matter to be investigated OR progress updates given OR if lengthy investigation required (include date/s given in notes and on the first page of form)
Action taken details
What were the issues discussed and/or from the investigation?
File upload: Action: Attach additional notes or documents (if required)

Cancelof
Investigation outcomes
What were the outcomes of the investigation?
File Upload: Investigation Outcomes: Attach additional notes or documents (if required)

Cancelof
Decisions Made
What were the decisions made?
What were the reasons for the decision made?
Options to have decisions reviewed provided to the affected person/s (refer Compliments and Complaints Management and Resolution Procedure for process)

YearMonthDay
Date
Other Comments
Signatures of parties involved with conversation and agreed outcomes
Reinforce

Complaint will be kept confidential and only disclosed in appropriate circumstances - i.e. legal requirement or separate written approval provided for non legal requirements.
Full Name Person 1

First NameLast Name
Organisation/Position Person 1
Signature Person 1

Clear
Date Person 1

YearMonthDay
Date
Full Name Person 2

First NameLast Name
Organisation/Position Person 2
Signature Person 2

Clear
Date Person 2

YearMonthDay
Date
Full Name Person 3

First NameLast Name
Organisation/Position Person 3
Signature Person 3

Clear
Date Person 3

YearMonthDay
Date
This record must be kept for 7 years from the date the record was made. Must be provided to Commission or quality auditor if requested.
Should be Empty:

Compliment/Complaint Record Form

Please be assured that all information is strictly confidential.

Personal Details of Person/Participant involved

Compliment or Complaint Details

Impacts

Complaint specific: Desired outcomes

Contact Details

OR If you choose to remain anonymous

Management Use Only

Relevant dates

Compliment/Complaint Details

Impacts: Important ALWAYS refer NDIS (Procedures Fairness) Guidelines 2018

Details of Answers provided

Action taken details

Investigation outcomes

Decisions Made

Signatures of parties involved with conversation and agreed outcomes