Form 6-5 Notification of Cessation of the Use of Restrictive Practices
- This form is to be completed by a relevant service provider, if the existing restrictive practice approval, is changed in any way, from that as previously notified, via Form 6-4. (Disability Services Regulation 2006, Section 8A(3), (Disability Services Regulation 2006, Section 8A(4)))
- The relevant service provider is required to complete and return this form to the Department of Communities, Child Safety and Disability Services within 14 days of the change of the restrictive practice approval for the client indicated in Part B. (Disability Services Regulation 2006, Section 8A(5))
How to complete this form
- Only therelevant sections of this form must be completed, starting at Part A – Include the Cessation date.
- This form must be completed with contact details and the declaration signed at Part E.
- Reporting instances of use of Restrictive Practices is required up until, and including the Cessation date.
- If completing this form manually, print clearly, using BLOCK letters and indicate with a cross(X) where required.
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 —Reason for completing
Change of Outlet / Provider – Complete Part B, complete relevant sections of Part C, complete Part D (as the outgoing outlet) and complete Part F.(If changing Outlet, Complete Part E)
Premature ceasing of PBSP, Respite/CAS Plan, STA or Appointment of a Guardian(ie; before the natural expiration of the previously supplied approval) – Complete Part B, complete relevant section ofPart C (Restrictive Practice/s information is not required to be indicated), complete Part D and complete Part F.
Removal of entire Restrictive Practice/s – Complete Part B, complete Part C (indicate approval type and Restrictive Practice/s),complete Part D and complete part F.
Date of Cessation (Reporting instances of use is required up until and including this date) / /
Death of Client – Complete Date of Death, Part B and Part F. / Date of Death / /
PART B — Details of Adult
Surname / First name Name / Date of Birth / /
Gender / Male / Female / BISID / – / NDIS ID
PART C — Approval / Consent Details (Complete only the ceasing components)
Appointment of Guardian / Guardian Name:
Plan/Approval Type: / PBSP / Respite/CAS Plan / Dated: / / / Short Term Approval
As Approved by / OR / Consentfrom / Public Guardian / Delegate of the Chief Executive
QCAT / Guardian for RP (General) / Informal Decision Maker / Guardian for RP (Respite)
Related Restrictive Practice/s: / Containment / Seclusion / Chemical Restraint
Restricted Access / Item or Location:
Mechanical Restraint / Device:
Physical Restraint / Method:
Part D – Ceasing Provider Outlet details – Applicable Outlet information
Outlet Name / Outlet Reference
Part E – New Provider Outlet details – Current Provider only
OUTLETName / OUTLET Reference
Address / Suburb / Postcode
Effective Date / / / The from date this outlet is providing services and using restrictive practices.
Part F – Declaration
(Registered name of association or company)
Trading as of
(Street address)
Telephone number: (07) .
Facsimile number: (07) .
Email address: @,
does herebysubmit a notification under Section 195(5) 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.
RPCessNotif: Approved Restrictive Practice ReportingPage 1 of 2
Issue 02Date: 16/03/2016