Complaint and Feedback Report

Version number: 2

Date: 29/05/2025

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

What are you submitting: *

Complaint Feedback

Date: *

Part A - About Me

If you want to raise this complaint anomymously, DO NOT complete Part A.

If this complaint is being raised anonymously, this can be posted by mail to the company's address.

Name:

Contact Number:

Address:

If complaint: Is there someone else (legal representative or support person) that you would like involved in making this complaint?

YesNo

Name of legal representative/support person:

Fill in this box if you are putting this complaint/feedback on behalf of someone else

Name of person

What is your relationship with that person?

Contact Number:

Does the person know you are making this complaint

YesNo

Does the person consent to the complaint being made?

Yes No

What is your feedback/complaint? *

Was there a witness?

Would they be willing to be contacted? If yes, please provide contact details.

What outcome/actions would you like for us to do? *

Issue Type

Description of the issue *

Root Cause Analysis *

Proposed immediate and Corrective Actions (include by when/date completed) *

Name of Person verifying actions taken *

Signature *

Draw signature|Type signatureClear

Date closed *