Phone Number: 1800 934 115
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Care Zone

Feedback and Complaints Management Form

Feedback and Complaints Management Form

Please complete the form below. A member of the Care Zone team will review your submission.

Fields marked * are required.

Step 1 of 5

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.
Participant's Name*
Date of Birth*
Preferred method of contact*
Phone*
Participant’s Representative (if applicable)
Email*
Address*
SECTION - COMPLAINT DETAILS (TO BE COMPLETED BY PARTICIPANT OR PARTICIPANT'S REPRESENTATIVE)
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.
Report Completed by*
Signature*
Once Completed and Signed, click the Submit Button at the end of this page.
Date Report Completed*
Step 2 of 5

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?
Preliminary Findings:
Identified Root Cause for the Complaint
Step 3 of 5

REQUIRED ACTIONS

Description of Actions and Any additional comments
Outcome of Complaint
Status of Complaint
Step 4 of 5

NOTIFICATION

NDIS consultation required?
Complaint resolved?
Results communicated with Participant?
Date of NDIS Consultation
Step 5 of 5

Sign off

Investigation Completed by
Signature
Phone:
Date:

Your responses are submitted securely and stored in Care Zone's confidential records.