We Rock The Spectrum Geelong - Health Information and Participant Risk Assessment

WRTS Participant Risk Assessment and Health Information Form

Service Provider: WRTS Franchising (Australia) | NDIS Provider Number: 4050036577
WRTS conducts regular Risk Assessments in consulation with staff, participants, and relevant stakeholders, covering at least the following areas:
- Incident Management;
- Complaints Management and Resolution;
- Occupational Health and Safety;
- Human Resource Management;
- Financial Management;
- Information Management;
- Governance and Operational Management [including continuity of supports];
- Emergency and Disaster Management.
Please ensure you complete this form honestly. This is a mandatory requirement for Group Programs or Drop Off Program attendance.
Date of Participant Risk Assessment (Today's Date)*

DayMonthYear
Date
Date of Review (Minimum Annually)

DayMonthYear
Date
WRTS Gym Location
Child/Participant Information
Child's Name*

First NameLast Name
Birth Date*

DayMonthYear
NDIS Number, if applicable.
Preferred Language
Parent/Guardian Information
Name*

First NameLast Name
Preferred Contact Number*

Area CodePhone Number
E-mail*
Additional Contact*

First NameLast Name
Additional Contact Number*

Area CodePhone Number
Relationship
General

Please answer the below questions to the best of your ability.
1. Can the Participant/Child effectively communicate their wants and needs to others? (details of the participants communication methods must be recorded within the participants support plan).*

YESNO
2. Is the participant able to understand and provide consent?*

YESNO
3. Without receiving support from another person, does the participant have the capacity to understand the potential risks or dangers associated with an activity?*

YESNO
4. Has the participant ever exercised force, towards any person including a caregiver that caused or could have caused injury?*

YESNO
5. Has the participant ever deliberately broken or damaged an item or place?*

YESNO
6. Is the behaviour of the participant unpredictable?*

YESNO
7. Is the participant aware of their surroundings and able to avoid danger? ie: swings, road dangers, etc.*

YESNO
8. Does the participant understand the concept of vehicle and road safety behaviours?*

YESNO
9. Is the participant currently taking any mental health related medications?*

YESNO
10. To what extent does the participant rely upon receiving supports and services to meet their daily living needs?
11. To what extent would the participant's health and safety be affected if the supports and services usually provided to them were disrupted?
Please provide further details for any of the above items.
Behaviour Support and Behaviours of Concern.

Please answer the below questions to the best of your ability. Please select any current or historic behaviours, even those that may have been reported to you without seeing them yourself.
12. Does the participant display and engage in any behaviours of concern?*

YESNO
If yes to the above Q 12: Please provide further details.
13. Does the participant have a current Positive Behaviour Support Plan in place? (if yes, a copy of the BSP should be shared and uploaded in the space below).*

YESNO
Please Upload a Copy of the Behavioural Support Plan here.

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14. Does the participant current supports include the use of Approved Restrictive Practices, as per their Positive Behaviour Support Plan?*

YESNO
15. Does the participant engage in any self-stimulatory behaviours? ie: stims.*

YESNO
If yes to the above Q 15: Please provide further details.
16. Has the participant ever exercised force, towards another person (adult or child) that caused or could have caused injury?*

YESNO
17. Is the participant likely to have access to weapons?*

YESNO
18. Do changes to the participants routine cause the participant to become distressed?*

YESNO
19. Does the participant engage in behaviours such as playing with fire or sharp objects such as knives?*

YESNO
20. Physical Assault (includes a wide range of behaviours such as hitting, kicking, punching, spitting, biting, pinching, etc)*

YESNO
If yes to the above Q 20: Please provide further details.
21. Verbal Abuse (eg: yelling, screaming, swearing, name-calling, making threats, bullying behaviours, etc)*

YESNO
If yes to the above Q 21: Please provide further details.
22. Throwing Objects (either generally or directly at a person, includes throwing bodily fluids)*

YESNO
23. Harassment or Stalking of another person/s*

YESNO
24. Intimidation of others (includes making threats to them)*

YESNO
25. Mouthing/Eating inedible items/products (includes PICA)*

YESNO
26. Self-harming/injury behaviours (includes a wide range of behaviours such as cutting, skin pricking, biting self, head banging, etc)*

YESNO
If yes to the above Q 26: Please provide further details.
27. Suicide Risk*

YESNO
28. Absconding from Environment*

YESNO
29. Climbing beyond equipment limits*

YESNO
30. Intrusiveness (eg; awareness of personal space for self and others, etc)*

YESNO
31. Impulsive Behaviours*

YESNO
32. Withdrawal (from group settings, activities, friendship altercations, etc)*

YESNO
33. Refusal to follow instructions or complete tasks (includes when heightened/overwhelmed, non-compliance)*

YESNO
34. Damage or destruction of property*

YESNO
35. Harming animals*

YESNO
36. Exploitation of others*

YESNO
37. Inappropriate Sexual Behaviours (includes a wide range of behaviours such as discussing inappropriate sexual topics, making obscene gestures, undressing in public, non-consensual touching of another person, exposing and/or touching of own body parts in a non private setting, invasion of bathroom privacy, etc)*

YESNO
37. Self-stimulatory behaviours (includes a wide range of behaviours such as repetitive movements like rocking, arm flapping, holding their ears, echolalia, lining items up, etc)*

YESNO
38. Does the participant engage in criminal/illegal behaviours or activities?*

YESNO
39. Is the participant at risk of domestic or family violence?*

YESNO
40. Is the participant currently under a protection order? (AVO, DVO - if yes, we require a copy of this documentation)*

YESNO
41. Is the participant at risk of exploitation by others? (including physical, emotional and financial)*

YESNO
42. Does the participant understand the concept of 'Stranger Danger'?*

YESNO
43. Does the participant display hoarding behaviours?*

YESNO
If answered yes to any of the above questions, Please provide further details where necessary.
Allergies | Medications | Eating and Drinking | Medical Interventions | Financial | Mobility and Manual Handling

Please answer the below questions to the best of your ability.
44. Does the participant have any medical conditions or illnesses? (including a mental illness diagnosis)*

YESNO
If yes to the above Q44: Please provide further details.
45. Does the participant have any allergies? (food and environmental included please)*

YESNO
If yes to the above Q45: Please provide further details.
46. At the time of the risk assessment being undertaken, is the participant currently well?*

YESNO
47. Is the participant currently undergoing any medical assessments or procedures?*

YESNO
48. Is the participant currently receiving any mental health supports?*

YESNO
49. Does the participant experience seizures or have a history of seizures?*

YESNO
If yes to the above Q49: Please provide further details.
50. Does the participant experience any involuntary movements or tics? (vocal or motor tics)*

YESNO
If yes to the above Q50: Please provide further details.
51. Does the participant experience any incontinence or constipation?*

YESNO
51. Does the participant require any assistance for toileting?*

YESNO
52. Is the participant currently taking any health related medications or supplements?*

YESNO
53. Does the participant's daily health and safety rely upon any medications being taken? (eg: insulin, etc)*

YESNO
If yes to the above Q53: Please provide further details.
54. Does the participant use an inhaler, nebuliser or spacer?*

YESNO
If yes to above, please upload a copy of the participant's Asthma Action Plan.

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55. Is the participant able to take medication orally? (either tablets or liquid)*

YESNO
56. Does the participant require any medications to be administered intravenously (whilst within our care)?*

YESNO
57. Does the participant rely on enteral medication administration?*

YESNO
58. Does the participant have a history of medication refusal?*

YESNO
59. Does the participant have any allergies or medical alerts?*

YESNO
If yes to the above Q59: Please provide further details.
60. Does the participant require an EpiPen?*

YESNO
If yes to above, Please upload a copy of the Anaphylaxis Plan.

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61. Does the participant have a history of experiencing a reaction to any medications or vaccines?*

YESNO
62. Does the participant experience any skin reactions to common dressings such as band-aids, micropore, etc?*

YESNO
63. Does the participant have a current Mealtime Management Plan in place?*

YESNO
If yes to the above Q63: Please provide further details.
64. Is the participant reliant on enteral feeding only?*

YESNO
65. Does the participant have a history of food or fluids refusal?*

YESNO
66. Is the participant at risk of mouthing or eating inedible objects?*

YESNO
67. Does the participant experience significant levels of distress within a clinical setting? (eg: doctors office, dental clinic, OT or physio space)*

YESNO
68. Does the participant tolerate band-aids or other dressings being applied to the skin?*

YESNO
69. Does the participant tolerate the application of any creams or lotions to the skin?*

YESNO
70. Is the participant able to undergo a blood test or injection, without medical intervention supports? (eg: sedation)*

YESNO
71. Does the participant have a history of medical examination or procedure refusal?*

YESNO
72. Does the participant have a history of refusal to attend medical appointments?*

YESNO
73. Does the participant understand the concept of money? (ie: the value of money, is to recognise correct change, etc)*

YESNO
74. Is the participant able to manage their belongings independently? (ie: looking after their clothing, drink bottles, put belongings back in bags, etc)*

YESNO
75. Does the participant inappropriately give money or other belongings away?*

YESNO
76. Does the participant regularly lend money or other belongings to others?*

YESNO
77. Does the participant try to or successfully borrow money or other belongings from others?*

YESNO
78. Does the participant engage in impulsive spending?*

YESNO
79. Does the participant use any aids or equipment to assist their mobility?*

YESNO
If yes to the above Q79: Please provide further details.
80. Is the participant able to independently move around their home?*

YESNO
81. Is the participant able to independently able to move about within the community?*

YESNO
82. Are there any concerns regarding the participants ability to balance?*

YESNO
83. Does the participant regularly stumble. trip over or bump into things?*

YESNO
84. Is the participant considered to be a 'falls risk'?*

YESNO
85. Does the participant require any manual transfers?*

YESNO
If yes to the above Q85. Please upload the Participant's Support Plan to reflect these requests.

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85. Does the participant have any physical limitations that we should be aware of?*

YESNO
If yes to the above Q85. Please provide further details.
What is your child's preferred model of communication? *
If answered yes to any of the above questions, Please provide further details where necessary.
Finally, please list any and all of your child's interests and things that may motivate them.
All this information can help us provide the best possible care for your child!
NDIS Funding
Will you be using NDIS funding?*

YES - I am Self ManagedYES - I am NDIA ManagedYES - I am Plan ManagedNo
If using NDIS funding, what is your child's NDIS number?
Please note, additional We Rock the Spectrum NDIS service agreement must be completed by all participants who will be using NDIS Funding to visit We Rock The Spectrum.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, YOU ARE RECOGNISING THAT WE ROCK THE SPECTRUM KIDS GYMS ARE NOT LICENSED CHILDCARE FACILITIES.

PLEASE NOTE, FURTHER DISCUSSIONS MAY BE REQUIRED TO BE ABLE TO PROVIDE THE BEST POSSIBLE CARE FOR THE PARTICIPANT. THERE ARE PREREQUISITES FOR OUR GROUP AND DROP OFF PROGRAMS THAT REQUIRE PARTICIPANTS TO ATTEND AN OPEN PLAY SESSION PRIOR TO COMMENCEMENT OF PROGRAMS.
Signature*
Date*

DayMonthYear
Date
Should be Empty:

WRTS Participant Risk Assessment and Health Information Form

General

Behaviour Support and Behaviours of Concern.

Allergies | Medications | Eating and Drinking | Medical Interventions | Financial | Mobility and Manual Handling

NDIS Funding