Alfa Home Care

This form is to assist you in making a complaint/feedback to our organisation. All persons wishing to make a complaint/feedback can speak with the Manager or staff member of choice or choose to complete this form. You can also speak to the Director on 0431385681. If you are unhappy with the solution or want to contact NDIS Quality & Safeguards Commission, you can contact them on 1800 035 544.

All information is strictly confidential.

If you feel unsure about anything or would like help to complete this form, please speak to the Administration Officer.

We encourage you to make your complaint/feedback in writing. Please allow a maximum of ten (10) days for a response.

Personal Details

Referee Details

Personal Details(Optional)

Name

Postal Address

Postcode

Phone No.

Mobile

Have you lodged a complaint/feedback with our organisation before?

Yes , the matter was resolved

No, the matter was not resolved

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

Yes

Name of legal representative/support person

Postal Address

Phone

Is the complaint related to:

Complaint Details

What happened?

When it happened? (Include date if possible)

Who was involved? (List all persons involved and witnesses)

Did someone witness the incident? Would they be willing to be contacted regarding your complaint/feedback? If so, provide the name and contact details. (Inform the witness that they may be contacted by the organisation to discuss the matter.)

Any other relevant details:

Have you discussed the matter with the person/s involved?

Yes

If yes, what was the outcome, if any? Please attach a copy (not the original) of your complaint/feedback to the respondent and any letter of reply you have received.

If no, is there any reason/s that you cannot do so? Do you need help to do this, e.g. for safety reasons, cultural reasons?