Yes This form is to be used to report a reportable assault No as required under s63-1AA of the Aged Care Act 1997. Is this report related to: Your contact details Unreasonable use of force or assault Mr Mrs Miss Ms Unlawful sexual contact Please provide the date and time the Other allegation/suspicion was made known to the person responsible for reporting reportable Surname assaults: Date Given name Time Has the reportable assault been reported to the Position/role (e.g. CEO key personnel, registered police? nurse, etc.) No report the assault to the police prior to completing this form Work number Yes Date Mobile number Time Incident number: Email address Note: A departmental officer may contact you to Police station reported to (if applicable): seek further information in relation to this report. Approved provider and service details Have the police arrested or charged a person in relation to this reportable assault? Name of the aged care service this report relates to: No Yes Do not know RACS ID: Name of the approved provider this report relates to: What action has been taken to ensure the health, safety and wellbeing of those care recipients involved in the reportable assault and/or other care recipients at the service? Reportable assault details Are you making this report on behalf of the approved provider?
This form is to be used to report a reportable assault as required under s63-1AA of the Aged Care Act 1997. Your contact details Mr Mrs Miss Ms Other Surname Given name Position/role (e.g. CEO key personnel, registered nurse, etc.) Work number Mobile number Email address Note: A departmental officer may contact you to seek further information in relation to this report. Approved provider and service details Name of the aged care service this report relates to: RACS ID: Name of the approved provider this report relates to: Reportable assault details Are you making this report on behalf of the approved provider? Yes No Is this report related to: Unreasonable use of force or assault Unlawful sexual contact Please provide the date and time the allegation/suspicion was made known to the person responsible for reporting reportable assaults: Date Time Has the reportable assault been reported to the police? No report the assault to the police prior to completing this form Yes Date Time Incident number: Police station reported to (if applicable): Have the police arrested or charged a person in relation to this reportable assault? No Yes Do not know What action has been taken to ensure the health, safety and wellbeing of those care recipients involved in the reportable assault and/or other care recipients at the service?
final_draft_reportable_assault_notification_-_online_form.docx