NDIS Participant Risk Assessment Form
PARTICIPANT DETAILS
Name
First Name
Last Name
DOB
-
Day
-
Month
Year
Date
NDIS Number
PARTICIPANT RISKS
Medical conditions and interventions (select all that apply)
*
Fractures, Cuts
Bruises, Abrasions
Seizures
Respiratory Conditions
Infectious Disease
Skin Conditions
Endocrine Conditions
Diabetes
Sleep Disorder
Constipation
Incontinence
Dementia
Obesity
Teeth and Gum Disease
Missed Appointments
Night-Time Checking
Medication
Medication Non-Adherence
Procedure Refusals
Allergies
Other
None
If Other, please specify
Additional information for any items selected above
Eating and drinking (select all that apply)
*
Difficulty Swallowing
Choking
Enteral feeds - with oral intake
Enteral feeds - nil by mouth
Food Allergies
Specialised Diet
Texture Modified Diet
Thickened Fluids
Overnight feeding required
Food Refusal
Dehydration
Posture and Positioning
Alertness
Modified Utensils/Equipment
Behaviour related to eating/drinking
Eating Non-Food Items
Other
None
If Other, please specify
Additional information for any items selected above
Accidental movement (select all that apply)
*
Startle Reflex
Panic Behaviour
Grabbing, Holding, Leaning
Sudden Body Movements
Trips/Falls
Bumping/Running into things
Other
None
If Other, please specify
Additional information for any items selected above
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NDIS Participant Risk Assessment Form
PARTICIPANT RISKS (CONT'D)
Environmental risks (select all that apply)
*
Electrocution
Sharps/knives
Fire Lighting/Flammables
Poisons
Smoking
Water Hazard
Sun Exposure
Wandering, Absconding
Traffic
Transport (public or private)
Other
None
If Other, please specify
Additional information for any items selected above
Mental health and wellbeing (select all that apply)
*
Suicide risk
Hoarding
Self-harm/injury
Mental Health Diagnosis
Self-neglect
Other
None
If Other, please specify
Additional information for any items selected above
Financial risks (select all that apply)
*
Low income
Limited understanding of money
Challenges developing/sticking to budgets
Debt
Vulnerable to financial exploitation
Gambling
Losing wallet/purse/bag
Other
None
If Other, please specify
Additional information for any items selected above
Social risks (select all that apply)
*
Exploitation
Anti-social peers
Harrassment/stalking
Discrimination
Using projectiles/weapons
Unsafe sex
Illegal behaviour
Emotional abuse
Property damage
Social isolation
Other housemates
Homelessness
Physical abuse/threats
Sexual abuse/threats
Harm to animals
Lack of informal supports
Other visitors to home
Leaving care
Verbal abuse/threats
Neglect
Domestic violence
Strangers
Family and carers
Other
None
If Other, please specify
Additional information for any items selected above
Substance use (select all that apply)
*
Alcohol
Smoking
Medication Misuse
Other
Drugs
None
If Other, please specify
Additional information for any items selected above
RISK MITIGATION/ACTION PLAN
Are there any current plans/strategies in place to mitigate the risks identified above? (please detail here)
Risk Action Plan
Rows
Identified Risk
Risk Rating (High, Medium, Low)
Action Required
Completed By
Completed Date
1
2
3
4
5
6
7
ACKNOWLEDGEMENT/SIGNATURE
TO BE COMPLETED ONCE ACTION PLAN IS CONFIRMED
Do you agree to the Action Plan above?
Yes
No
Form Completed By
First Name
Last Name
Completed On
-
Day
-
Month
Year
Date
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