Complaint / Feedback Form

Complaint / Feedback Form
This form is to assist you in making a complaint/feedback to our organisation.

All persons wishing to make a complaint/feedback can speak with the Manager or staff member of choice or choose to complete this form. You can also speak to the Director on 0431583477 or 0466 098 949.

If you are unhappy with the solution or want to contact NDIS Quality & Safeguards Commission, you can contact them on 1800 035 544.

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/feedback in writing. Please allow a maximum of ten (10) days for a response.
Personal details (Optional)
The information provided will be used to contact you. Only provide the contact details that you wish to be contacted on.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Date of Complaint

MonthDayYear
Date
Have you lodged a complaint/feedback with our organisation before?

YESNO
Was the matter resolved? Comments:
Is there someone else (legal representative or support person) that you would like involved in making this complaint/feedback?

YesNo
Name of legal representative/support person

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Details of the Complaint / Feedback
Is the complaint related to

Employee of the organisationVolunteer of the organisationStudent of the organisationService deliverySpecific incident
What happened?
Where it happened ?
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/feedback? 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/feedback 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, cultural reasons?
How would you like to see your complaint resolved? What action would you like the organisation to take to resolve your complaint?
Additional information/supporting documentation
Please 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 up to date. If details change, let the organisation know as soon as you can.
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Note

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.

NDIS Commission link for complaints:

https://www.ndiscommission.gov.au/about/complaints
Should be Empty:

Complaint / Feedback Form

Personal details (Optional)

Details of the Complaint / Feedback

Additional information/supporting documentation