Complaints & Feedback Register
What are you submitting?
Complaint
Compliment
Feedback
Are you filling this form out on behalf of someone else?
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What is your name?
If you want to be contacted regarding your feedback, please fill this section out
Relationship to client
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Customer Name
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I have received consent from the client to submit this feedback on their behalf
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Contact Number
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This will be the number we contact to discuss the feedback
Email Address
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This will be the email we contact to discuss the feedback
Is this in relation to an NDIS Participant?
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Yes
No
What site does this relate to?
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ANZ
Beerwah
Chermside
Nepean
Date of Occurence
Date of occurrence refers to the date in which the interaction, appointment and/or incident happened.
Please provide a detailed description of what happened
Please be as specific as possible, things to mention may include: names, time, location on site (reception area, practitioner room etc.), expectations and impact on you
(Optional) Please provide any supporting documents
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E.g. Receipts, photos, documents
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I have read and give consent to the processing of my feedback in accordance to the privacy policy above.
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Date of Investigation
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Involved parties interviewed
Please include who was interviewed and what their account of the feedback is.
Was there any evidence provided?
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Yes
No
Please elaborate on what evidence was provided
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What are the mitigating factors
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e.g. Genuine mistake, miscommunication, negligence, unaware of policy, response to provocation
Area of Feedback
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Customer Service
Booking Process
Clinical
Medical Process
Other
Please specify:
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What actions were taken to find out all information
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What is the outcome of the investigation and plans to rectify?
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Please enter the date this feedback has been closed
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Has the Feedback provider been contacted?
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Yes
No
How was the feedback provider contacted?
Please include method of communication and date.
Why was the feedback provider not contacted?
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Copy of Feedback provided to contact
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Was the feedback provider happy with the outcome?
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Yes
No
Has the feedback been provided to the individual/parties involved?
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Yes
No
Is there any further follow-up actions required
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Any additional comments?
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