Complaint Form (NDIS Related)
Boon Consulting
Participant and Contact Details
NDIS Participant Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
NDIS Number
Phone or Mobile Number
Email Address
Residential Address
Street Address
Street Address Line 2
City
State
Post Code
Alternative Contact Person Name
First Name
Last Name
Relationship to the NDIS participant
Support Coordinator
Plan Manager
NDIS Provider
Parent / Child Representative
Spouse / Partner
Other Relative / Friend
Other
If Other
Phone or Mobile Number
Email Address
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Complaint & Consent
Name of person making this complaint
First Name
Last Name
If you are not the participant, does the participant know you are making this complaint?
Yes
No
If yes, please confirm how and when consent was provided.
If no, please explain why not.
Who will be the primary contact for this complaint?
Participant
Contact Person
Signature of Participant
Date Signed
-
Day
-
Month
Year
Signature of alternative contact person
Signature Collected
/
Day
/
Month
Year
Hour Minutes
AM
PM
AM/PM Option
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Complaint Details
Date of complaint
-
Day
-
Month
Year
Date/s of incidents this complaint is about
This can be single date, or over a period of time
Who is involved in the events that led to this complaint being made?
Was a disability provider involved?
Company and/or person's name
How can the disability provider be contacted?
Include as many details as possible
Describe the events that led to this complaint being made
Include as many details as possible
How did you first become aware of the problem?
Include as many details as possible
How and when did you make the provider aware of your concerns?
Include as many details as possible
What was the response you received?
Include as many details as possible
What other action (if any) have you taken to resolve the situation?
Include as many details as possible. This could include seeking advice from regulatory bodies, meetings and correspondence with the provider, requests for information etc.
What action (if any) has the provider taken to resolve the situation?
Include as many details as possible. This could include seeking advice from regulatory bodies, meetings and correspondence with the provider, requests for information etc.
What outcome are you hoping for by making this complaint?
Include as many details as possible
What impact has this situation had on the participant and their informal and other formal supports?
Include as many details as possible
Is the participant at risk of harm as a result of this situation?
If so, please describe the risk and whether any other supports are being provided to reduce the impact of this situation.
Is there any other information that might be relevant?
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