PARTICIPANT COMPLAINT FORM

This form is to assist you in making a complaint to our organisation.

- All persons wishing to make a complaint can speak with the Manager or staff member of choice or choose to complete this form.
- All information is strictly confidential.
- If you feel unsure about anything or would like help to complete this form, please speak to the Administration Officer.
- We encourage you to make your complaint in writing. Please allow a maximum of ten (10) days for a response.
- If you wish to remain anonymous, you do not need to provide any personal details and can mail the form to J Bromilow CHAMP Enterprises Pty Ltd, PO Box 296, Blaxland NSW 2774.

Personal Details:
The information provided will be used to contact you. Only provide the contact details that you wish to be contacted on.

A complaint can be made to the NDIS Commission by:
Phoning: 1800 035 544 (free call from landlines) or TTY 133 677. Interpreters can be
arranged.
- National Relay Service and ask for 1800 035 544.
- Completing a complaint contact form.

The NDIS Commission can take complaints from anyone about:
- NDIS services or supports that were not provided in a safe and respectful way
- NDIS services and supports that were not delivered to an appropriate standard
- How an NDIS provider has managed a complaint about services or supports provided
to an NDIS participant

As well as dealing with complaints, the NDIS Commission works to educate providers about delivering quality and safe supports, and effectively responding to complaints. If a complaint raises a serious compliance issue, the NDIS Commission has powers to take action.

Title

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Do you need assistance completing this form? If so, please select who will beassisting you.

CarerAdvocateGuardianTranslator

Name

First NameLast Name

Have you lodged a complaint with our organisation before? If yes, was the matter resolved?

No? Add comments below

Is there someone else (legal representative or support person) that you would likeinvolved in making this complaint? If yes, what is the name of legal representative/support person?

Details of the complaint. Is the complaint related to:

Employees of the organisation

What happened?

Where did it happen?

When it happened? (Include date if possible)

Who was involved? (List all person involved and witnesses)

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 the organisation to discuss the matter.)

Any other relevant details:

Have you discussed the matter with the person/s involved?

YESNO

If yes, what was the outcome, if any? Please attach a copy (not the original) of your complaint to the respondent and any letter of reply you have received.

If no, is there any reason/s that you cannot do so? Do you need help to do this, e.g. for safety reasons or cultural reasons?

How would you like to see your complaint resolved? What action would you like theorganisation to take to resolve your complaint?

Additional Information/Supporting DocumentationPlease attach copies (not the original) of any documents that may help us to handle the complaint, e.g. if you have letters, emails or faxes or records of conversations you have had with the person/s associated with the complaint.To help us resolve this matter as fast as we can, please ensure your contact details are kept upto date. If details change, let the organisation know as soon as you can.

Please sign and date the form.

For J Bromilow CHAMP Enterprises Pty Ltd T/A NDIS Financial Care Plus use only.

Complaint Investigation

Complaint Number

Relevant Department:

To be Investigated By:

Investigator Remarks: