Feedback & Complaints

1

Would you like to remain anonymous?* This field is required.

No — share my details

Yes — I want to stay anonymous

2

I am a…* This field is required.

3

Are you the nominated representative?* This field is required.A nominated representative is someone authorised to make care or financial decisions on the consumer's behalf.

Yes

No

4

Are you lodging this feedback on behalf of:* This field is required.

Yourself

A consumer

5

Your full name* This field is required.★ | First + Last (or use a single Short Text if you prefer)

First Name

Last Name

6

Email

example@example.com

7

Phone Number

Area Code

Phone Number

8

Address

Street

Suburb

State

PostCode

Country

9

Preferred way to contact you

Email

Phone

Post

Don't contact me

10

Preferred language

11

Consumer / resident's name

12

Room or unit number

13

Is the consumer aware you are submitting this feedback?

Yes

No

14

Facility / location

15

Care area

16

Have you already spoken to a staff member about this?

Yes

No

17

Name of the staff member you spoke to

18

What kind of feedback is this?

👍 Compliment

💡 Suggestion

⚠️ Concern

❗ Complaint

19

Category

20

Subject - a short summarisation

21

Description

22

Date the issue occurred

Date

23

Specific location (optional)

24

Witnesses (optional)

25

Attachments (optional)

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

26

How urgent is this?

Routine (within 28 days)

Important (within 7 days)

Urgent (within 48 hours)

Critical (immediate harm)

27

Has anyone been harmed?

28

Is there a current safety concern that needs urgent attention?

Yes

No

Unsure

29

May we contact you about this submission?

Yes

No