"*" indicates required fields Name of person making the complaint*Phone*Email* 1. Address*2. Date of Complaint* DD dash MM dash YYYY 3. How is the service that is the subject of the complaint funded? (Please select all that apply) NDIS Managed (Agency Managed) Plan Managed Self Managed 4.Which of the following service types are subject to the complaint? (please select all that apply) Household Task / Cleaning Gardening / Yard maintenance Independent living and life skills training Community Nursing Participation in community, social and civic activities Personal care / Self Care assistance Support Coordination Equipment / Consumables Therapy or Therapeutic supports Other (please specify) 5. Which of the following describes the reason(s) for the complaint (as reported to the complainant?) (Please select all that apply)Staff related issues Knowledge/skills of workers Poor match between service user and workers (e.g. personality differences, gender, age or cultural preferences) Staff behaviour/attitude (e.g. inappropriate impolite, rude, lacked empathy High turnover of workers/staff rostering/staff attendance Concerns around discrimination, abuse, neglect, intimidation or bullying Other staff-related issue (please specify) Other staff-related issueService delivery/quality/standards Concerns around physical and personal health and safety (including physical environment) Dissatisfied with quality of services provided Insufficient service/care provided Concerns about lack of choice of service/activities Other service delivery/quality/standards issue (please specify) Other service delivery/quality/standards issueCommunication/relationships Insufficient communication by service provider Poor quality communication Other communication/relationship issue (please specify) Other communication/relationship issuePolicy/procedure Concerns about policies/procedures Privacy/breach of confidentiality The way complaints have been handled Other policy/procedure issue (please specify) Other policy/procedure issueOther (please specify)6. What was the outcome(s) sought by the complainant? (please select all that apply) Acknowledgement of complainant’s views or issues Explanation of information about services provided Change or appointment of a worker An apology (from your service) Access to an appropriate service Relocation/transfer to another service Change or review of decision A change in policy or procedure Performance management, discipline action, feedback or training for worker(s) at your service Other outcome (please specify) 7. How would you like to be contacted? Phone Email 8. Details of your complaintCAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
