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PART A - About Me
Full Name
NDIS Number
PART B - About The Complainant (if different from above)
Fill in this section if you are complaining on behalf of someone else
Name of person:
Text
Does the person know you are making this complaint?
Yes
No
Does the person consent to the complaint being made?
Yes
No
Fill in this section if someone is assisting you with the complaint – for example a family member, your nominee or representative.
Name of representative:
Organisation
Postal Address
Contact Details
Mobile Number
Business Number
Fax Number
TTY
Email Address
My preferred contact is:
Mobile
Business Number
Fax
TTY
Email
PART C - Your complaint or feedback
What is your complaint or feedback about?
What outcomes are you seeking?
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