Complaint Report Form
This form is to assist you in making a complaint to our organisation.
All persons wishing to make a complaint can speak with the Manager or staff member of choice or choose to complete this form.
All information is strictly confidential.
If you feel unsure about anything or would like help to complete this form, please speak to the admin person.
We encourage you to make your complaint in writing. Please allow a maximum of ten (10) days for a response.
Please attach copies (not the original) of any documents that may help us to handle the complaint.
If you still wish to raise this complaint about us to the NDIS commission, please contact 1800 035 544.
Part A – About me :
(If you want to raise this complaint anonymously, DO NOT complete Part A)
If this complaint is being raised anonymously, this can be posted by mail to the company’s address.
Is there someone else (legal representative or support person) that you would like involved in making this complaint?
Yes
No
Name of legal representative/support person
Fill in this box if you are putting this complaint on behalf of someone else :
Does the person know you are making this complaint?
Yes
No
Does the person consent to the complaint being made?
Yes
No
Part B – Your complaint :
What is your complaint about?
(Provide some details to help us understand your concerns. You can include what happened, where it happened and who was involved)
Did someone witness the incident? Would they be willing to be contacted regarding your complaint? If so, provide the name and contact details.
(Inform the witness that they may be contacted by the organisation to discuss the matter).
Part C - How can we help to fix this problem or complaint? :
Please return this form to the office or email us
Office Use Only
I,
acknowledge receiving a Complaint Form submitted by
that has been allocated the registration number of
Is this complaint confidential?
Yes
No
Signature:
Date:
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Submit
