- By a Relevant Service Provider, after receiving any approval for the use of restrictive practices, at a Service Outlet (Disability Services Act 2006, Section 195).
- After each subsequent review and approval given for the use of restrictive practices.
- To record appointment of, or all changes to, guardianship.
Howto complete this form
Under theDisability Services Act 2006 a service outletmeans a place at which disability services are provided.
Limited restrictive practice approval means a restrictive practice approval other than—
a containment or seclusion approval; or
a short term approval given by the public guardian under the Guardianship and Administration Act 2000, chapter 5B, part 4.
- A relevant service provider is required to complete and return this form tothe Department of Communities, Child Safety and Disability Services within:
21 days after consent touse of a restrictive practice is given by either a guardian for a restrictive practice (general or respite) matter or an informal decision maker.
- This formmust be completed withcontact details and a signed declaration (Part D).
- Print clearly, using BLOCK lettersand indicate with a tick () where required.
- The ‘Provider Outlet Reference’ number must be completed.
Your privacy
The information on this form is being collected so Disability Services clinical teams can provide oversight and support in relation to the development, approval and use of positive behaviour support plans and restrictive practices. The collection is authorised by the Disability Services Act 2006. Information may be disclosed to statutory bodies and non-government service providers involved in this process, as part of that oversight and support functions. All personal information will be handled in accordance with the Information Privacy Act 2009.
Part A – Details of the Adult
Last Name / First Name / Date of Birth / /
Gender / Male / Female / BIS ID / - / NDIS ID
Address / Suburb / Postcode
Part B – Approval/Consent details
Who approved or gave consent to the use of the restrictive practice(s)?
Short Term Approval / Positive Behaviour Support Plan / Chemical Restraint (Fixed Dose) only
[No plan required – go to Part C]
Dated: / / / Respite/Community Access Plan
Delegate of the Chief Executive / QCAT / Dated: / /
Public Guardian / Guardian for RP (General) / Guardian for RP (Respite)
Relevant Decision Maker / Relevant Decision Maker
Period of Approval / Consent
Short Term Approval / Positive Behaviour Support Plan / Respite / Community Access Plan
/ / to / / / / / to / / / / / to / /
(period of approval) / (period of consent) / (period of consent)
Appointment of a Guardian for Restrictive Practices (general or respite)
Guardian for RP (General) / Guardian Name:
Guardian for RP (Respite) / Appointed from: / / to / /
What Restrictive Practices have been approved/consented to?
Containment / Seclusion / Chemical Restraint
Restricted Access / Item or Location:
Mechanical Restraint / Device:
Physical Restraint / Method:
Part C – Relevant Service Provider – Outlet details
OUTLET Name / OUTLET Reference
Address / Suburb / Postcode
Part D – Declaration
,
(Registered name of association or company)
trading as of
(Street address)
,
.
Telephone number: () .
Facsimile number: () .
Email address: @,
does herebysubmit a notification under Section 195(1) of the DisabilityServices Act 2006 and declare that all information supplied herein is true at the time of this notification.
Dated this day of 20.
Name: .
Position: .
Signature: …………………………………………..………...
Sign off should be bythe personwho has the appropriate authorityto sign on behalf of the companyorassociation.
Once completed, send form to:
Email:Director of Clinical Practice in your local region
Please check the Contact information section of the Positive Behaviour Support website for the latest details.
RPAppNotif: Approved Restrictive Practice ReportingPage 1 of 2
Issue 01Date: 18/09/2018