Complaint Management Form

COMPLAINTS MANAGEMENT FORM

Dear Participant / Representative,

We appreciate your input to further assist us in improving our service quality. Please complete the following form in the unfortunate event of any complaint.

A formal investigation will commence once we receive the completed form. If you require assistance in the completion of this form, please contact us with provided details. Please send the information to:

Email: info@carezoneservices.com.au

and/ or

Contact Us: 1800 934 115

Anonymous feedback/ complaints are accepted.

Please email details of your feedback/ complaint anonymously to info@carezoneservices.com.au

You may provide as much detail as you wish and may use this form amended to your discretion.

Alternatively, you may raise/ escalate your complaint directly to the NDIS Commission by:

Phone: 1800 035 544 (free call from landlines) or TTY 133 677.
Interpreters can be arranged. Call TIS National on 131 450.
National Relay Service and ask for 1800 035 544.
Completing a complaint contact form at the NDIS Quality and Safeguards Commission website.

Layout

Participant's Name

Date of Birth

Preferred method of contact

Phone
Email

Phone

Participant’s Representative (if applicable)

Email

Address

Address Line 1

City

State / Province / Region

SECTION - COMPLAINT DETAILS (TO BE COMPLETED BY PARTICIPANT OR PARTICIPANT'S REPRESENTATIVE)

Layout

Location of Incident

Witness Name (if applicable):

Name of the staff member present at the time of the incident

Time of Incident

Witness Phone (if applicable)

Date of Incident

Witness Email (if applicable)

Description of Events

Write details of the incident and complaint here.

Layout

Report Completed by

Signature

Once Completed and Signed, click the Submit Button at the end of this page.

Date Report Completed

OFFICE USE: (TO BE COMPLETED BY SERVICE PROVIDER)

Immediate Action and Measures taken by Service Provider

Any additional comments

Immediate actions and measures were satisfactory?

YES
NO

Preliminary Findings:

Identified Root Cause for the Complaint

REQUIRED ACTIONS

Description of Actions and Any additional comments

Outcome of Complaint

Status of Complaint

Open
More action required
Closed effectively

NOTIFICATION

Layout

Date of NDIS Consultation

Sign off

Layout

Investigation Completed by

Signature

Phone:

Date:

COMPLAINTS MANAGEMENT FORM

OFFICE USE: (TO BE COMPLETED BY SERVICE PROVIDER)

REQUIRED ACTIONS

NOTIFICATION

Sign off

USEFUL LINKS