Complaint Management Form

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Participant's Name *

Preferred method of contact *

Phone
Email

Participant’s Representative (if applicable)

Email *

Location of Incident *

Witness Name (if applicable):

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

Witness Email (if applicable)

Description of Events *

Write details of the incident and complaint here.

Report Completed by *

Immediate Action and Measures taken by Service Provider

Any additional comments

Immediate actions and measures were satisfactory?

Preliminary Findings:

Identified Root Cause for the Complaint

Skills and Competence
Workplace environment
Policies and Procedures
Communication
Risk Assessment
Others

Description of Actions and Any additional comments

Outcome of Complaint

Run Training / Induction session
Review / amend relevant process / documents.
Review / Update risk Register
Create a new procedure
Others

Status of Complaint

Open
More action required
Closed effectively

NDIS consultation required?

Complaint resolved?

Results communicated with Participant?

Investigation Completed by

Phone:

Empowering Abilities, Inspiring Possibilities.

As part of our mission, we strive to empower everyone with a disability to be considered equal members of the community.

Our focus is on the individual, not the disability.

________________________

ABN 90 961 408 022
Victoria, Australia
Phone: 1800 934 115
info@carezoneservices.com.au
www.carezoneservices.com.au

CARE ZONE acknowledges Aboriginal and Torres Strait Islander peoples as Traditional Owners of the lands and waterways of Australia. We pay our respects to the people, the cultures and the elders past, present and emerging.

We support Aboriginal people's right to self-determination and culturally safe services.

The Care Zone is committed to providing safe, accessible, and inclusive services to all members of the community.

NDIS Service Price Guide

(Employer ID: 4-JP95HRF)

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