WRTS Participant Risk Assessment & Health Information Form

WRTS Participant Risk Assessment & Health Information Form

Service Provider: WRTS Franchising (Australia) NDIS Provider No. 4050036577 Outlet: MOORABBIN
WRTS conducts regular Risk Assessments in consultation with staff, participants, and relevant stakeholders, covering at least the following areas:
incident management

·       complaints management and resolution
·       child safety and promoting a child safe environment
·       occupational health and safety
·       human resource management
·       financial management
·       information management
·       governance and operational management [including continuity of supports] and
·       emergency and disaster management
Date of Participant Risk Assessment

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Assessment Review Date (Annual)

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
WRTS Gym Location
Participant Representative Name
Participant Details
Participant Name

First NameLast Name
Email
Phone
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Preferred Language
Interpreter Required?
Completing this form

The Participant Risk Assessment Form is a requirement for NDIS Providers. The information is confidential and is designed to assist with supporting the participant. We understand some questions may not be relevant at this point in time, just answer as best as possible.
Please list interests or things your child likes doing.
Please list things that motivate or ways your child might be encouraged to participate.
Please list specific language and/or words, signs that will be helpful when communicating with the participant. Are there any gestures/signs the participant uses that will help staff in understanding them?
General

There are boxes at the end of each section to add comments. Please do so where necessary. This information will help staff know and support the participant.

Rows	YES	NO
1. Can the participant effectively communicate their wants and needs to others? (details of participant’s communication method must be recorded within the participants Support Plan)
2. Is the participant able to understand and provide consent?
3. Without receiving support from another person, does the participant have the capacity to understand the potential risks or dangers associated with an activity?
4. Has the participant ever exercised force, towards any person including a caregiver that caused or could have caused injury?
5. Has the participant ever deliberately broken or damaged an item or place?
6. Is the behaviour of the participant unpredictable?
7. Is the participant aware of their surroundings and able to avoid danger. i.e Swings, road dangers
8. Does the participant understand the concept of vehicle & road safety behaviours?
9. Is the participant currently taking any mental health related medication?

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

Rows	YES	NO
10. Does the participant display and engage in any behaviours of concern? (if yes, provide further details below)
11. Does the participant have a current Positive Behaviour Support Plan in place? (if yes, a copy of the PSBP should be recorded within the participants file)
12.. Does the participant current supports involve the use of Approved Restrictive Practices, as per their Positive Behaviour Support Plan?
13. Does the participant engage in any self-stimulatory behaviours? (ie. stims) (if yes, please provide further details below)
14. Has the participant ever exercised force, towards another person that caused or could have caused injury?
15. Is the participant likely to have access to weapons?
16. Do changes to the participants routine cause the participant to become distressed?
17. Does the participant engage in dangerous behaviours such as playing with fire or sharp objects such as knives?

Behaviours of Concern (Select any current or historic behaviours of concern)

Rows	YES	NO
18. Physical Assault (includes a wide range of behaviours such as hitting, kicking, punching, spitting, biting, pinching, etc)
19. Verbal Abuse (eg. yelling, screaming, swearing, name-calling, making threats, bullying behaviours etc)
20. Throwing objects (either generally or directly at a person, includes throwing bodily fluids)
21. Harassment or stalking of another person/s
22. Intimidation of others (includes making threats of harm)
23. Mouthing/Eating inedibles (including PICA)
24. Self-harming/injury behaviours (includes a wide range of behaviours such as cutting, skin picking, biting self, headbanging etc)
25. Suicide risk
26. Throwing objects (either generally or directly at a person, includes throwing bodily fluids)
27. Absconding from environment
28. Climbing
29. Intrusiveness
30. Impulsive behaviours
31. Refusal to follow instructions or complete tasks (Non-compliance)
32. Withdrawal
33. Damage or destruction of property
34. Harming animals
35. Exploitation of others
36. 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 etc)
37. Self-stimulatory behaviours (includes a wide range of behaviours such as repetitive movements like rocking, arm flapping, holding hands over their ears, echolalia, lining items up)

Details
Please provide further details on any of the above items.

Behaviours of Concern (Select any current or historic behaviours of concern)

Rows	YES	NO
38. Does the participant engage in criminal/illegal behaviours or activities?
39. Is the participant at risk of domestic or family violence?
40. Is the participant currently under a protection order? (AVO, DVO)
41. Is the participant at risk of exploitation by others? (Including physical, emotional and financial exploitation)
42. Is the participant at risk of unsafe sex?
43. Is the participant at risk of an unplanned pregnancy?
44. Does the participant understand the concept of ‘Stranger Danger’?
45. Does the participant display hoarding behaviours?

Details
Please provide further details on any of the above items.

Medical

Rows	YES	NO
46. Does the participant have any medical conditions or illnesses? (including a mental illness diagnosis) (if yes provide specific details below)
47. At the time of this risk assessment being undertaken, is the participant currently well? (ie. Is the participant currently sick or have any injuries eg. cuts or bruises)
48. Is the participant currently undergoing any medical assessments or procedures?
49. Is the participant currently receiving any mental health supports?
50. Does the participant experience seizures or have a history of seizures?
51. Does the participant experience any involuntary movements or tics? (vocal or motor tics) (if yes, please provide further details below)
52. Does the participant experience incontinence or constipation?
53. Is the participant experiencing any concerns relating to their dental health or personal hygiene?

Medication

Rows	YES	NO
54. Is the participant currently taking any health related medication or supplements? (list of any medications or supplements should be noted within the participant’s Support Plan)
55. Does the participant’s daily health and safety rely upon any medication being taken? (eg. insulin)(if yes, specific details of medication requirements must be documented within the participant’s Support Plan)
56. Does the participant use an inhaler, nebuliser or spacer?
57. Is the participant able to take medication orally? (either via tablet or liquid)
58. Does the participant require any medications be administered intravenously?
59. Does the participant rely upon enteral medication administration?
60. Does the participant have a history of medication refusal?

Allergies

Rows	YES	NO
61. Does the participant have any allergies or medical alerts?
62. Does the participant require an EpiPen?
63. Does the participant have a history of experiencing a reaction to any medications or vaccinations? (eg. anaphylaxis to penicillin etc)
64. Does the participant experience any skin reaction to common dressings such as band-aids, micropore etc?

Eating and Drinking

Rows	YES	NO
65. Does the participant have a current Mealtime Management Plan in place?
66. Is the participant reliant upon enteral feeding only?
67. Does the participant have a history of food or fluids refusal?
68. Is the participant at risk of mouthing or eating inedible objects? (including if participant has a PICA diagnosis)

Medical Interventions

Rows	YES	NO
69. Does the participant experience significant levels of distress within a clinical setting? (eg. Doctors office, dental clinic, OT or Physio space etc)
70. Does the participant tolerate band-aids or other dressings being applies to the skin?
71. Does the participant tolerate the application any cream or lotion to the skin?
72. Is the participant able to undergo a blood-test or injection, without medical intervention supports (eg. sedation)
73. Does the participant have a history of medical examination or procedure refusal?
74. Does the participant have a history of refusal to attend medical appointments?

Details
Please provide further details on any of the above items.

Financial Management

Rows	YES	NO
75. Does the participant understand the concept of money? (ie. the value of money, is to recognise correct change etc) (provide further details below if this understanding is limited)
76. Is the participant able to budget their finances independently?
77. Is the participant able to manage their belongings independently? (ie. Not lose their wallet, bag or purse)
78. Does the participant inappropriately give money away?
79. Does the participant regularly lend money to others?
80. Does the participant try to or successfully borrow money from others?
81. Does the participant engage in impulsive spending?

Details
Please provide further details on any of the above items.

Mobility and Manual Handling

Rows	YES	NO
82. Does the participant use any aids or equipment to assist their mobility? (if yes, provide further details below and document within the participant’s Support Plan)
83. Is the participant able to independently move around their home?
84. Is the participant able to independently move about within the community?
85. Are there current concerns regarding the participants ability to balance?
86. Does the participant regularly stumble, trip over or bump into things?
87. Is the participant considered to be a ‘falls risk’?
88. Does the participant require any manual transfers? (if yes, provide further details below and document within the participant’s Support Plan)

Details
Please provide further details on any of the above items.

Details of Risk Minimising Actions

Rows	Item No.(From lists above)	Risk Rating (refer to table below)	Actions needed to reduce/remove risk	Residual Risk Rating (refer	Completed YES/NO
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14
15.

If unable to complete actions - report to WRTS Management Team for further advice before commencing services
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Participant's Behaviour Supports
Please upload current Participant Behaviour Support Plan, if applicable

Cancelof
WRTS Assessor Name

First NameLast Name
Assessor Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

WRTS Participant Risk Assessment & Health Information Form

Participant Details

Completing this form

General

Positive Behaviour Support and Behaviours of Concern

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Participant's Behaviour Supports