Online Complaints Form - Confidential

Changed

Thursday, 20 December 2018 - 6:00pm

Please click on the check box below to confirm that you have reviewed the Notice of Collection that explains how we use personal information.

I have read the Notice of Collection *

Your Details

Title: *

First Name: *

Last Name: *

Street Address: *

Address Line 2:

City/Town/Suburb:

State/Territory

Postcode:

Phone: *

Email: *

Preferred contact method

From Time:

To Time:

If you want a time outside of the selectable range please provide details:

Complainant information

My complaint relates to: *

The care or services I am receiving The care or services someone else is receiving

Details of your complaint

Complaints can relate to care, catering, financial matters, hygiene, equipment, security, activities, choice, comfort and safety or other matters related to the responsibilities of an service provider. We cannot provide advice on who can make financial and medical decisions on behalf of a person receiving care and cannot provide legal advice. If we cannot help you, we will try to refer you to someone who can (unless you have submitted an anonymous complaint).

Have you discussed your complaint with the service? *

Yes No

Have you contacted anyone else regarding this complaint? *

Yes No

Further details about who you have discussed this complaint with

What does your complaint relate to You can optionally upload up to 5 related files here

Select file:

Please select up to 5 files (Files can be of type doc, docx, xls, xlms, pdf or jpg) and have a maximum size of 25MB in total for all the files.

Details of aged care service

What type of aged care service does the complaint or information relate to *

Service name: *

Service State/Territory *

Street Address: *

Address Line 2:

City/Town/Suburb:

Postcode:

Complaint resolution

Would you like to be involved in the resolution process?

Yes No

What outcome would you like from this complaint?

Would you like feedback on the resolution of this complaint?

Yes No

You are about to submit this complaint form to the Aged Care Quality and Safety Commission. If the matter you are raising involves a serious issue affecting the safety, health or wellbeing of a person receiving aged care, or if it relates to the commission of a serious offence, we may be obliged to refer relevant material to the appropriate external agency, including appropriate health professional regulatory bodies and the police.