/ Complaint notification
Children’s’ServicesAct1996,Children’sServicesRegulations2009

ThisformmustbecompletedandsenttotherelevantregionalofficeoftheDepartmentofEducationandTraining whenacomplainthasbeenreceivedbythechildren’sserviceallegingthat:

•thehealth,safetyorwellbeingofanychildbeingcaredfororeducatedbytheservicemayhavebeencompromised;or

•therehasbeenacontraventionoftheChildren’sServicesAct1996orChildren’sServicesRegulations2009(regulation105).

ContactdetailsforRegionalOfficescanbefoundat

Notificationofacomplaintallegingthat(select):

Thehealth,safetyorwellbeingofanychildbeingcaredfororeducatedbytheservicemayhavebeencompromised.TherehasbeenacontraventionoftheChildren’sServicesAct1996orChildren’sServicesRegulations2009.

Reportingrequirements

TheprescribedmannerfornotifyingtheSecretaryordelegateisbytelephonewithin48hoursfollowedbywrittennotificationassoonaspracticable.

Servicedetails

1.Name of Proprietor:LicenceID:

2. / NameofService:
3. / Address: / Postcode:
4. / Nameofcontactperson: / Phonenumber:
5. / Emailaddress:

Notifierdetails

6.Name:

7.Phonenumber(ifnotanemployeeoftheservice):

8.The notifier is the:LicenseePrimarynomineeNomineeOtheremployee

Other(specify)

Notificationdetails

9.Whenwasthelicensedchildren’sservicenotifiedofthecomplaint?

Date://Time::am/pm

VerballyBy telephone In writing 

10.Whenwasthedepartmentnotifiedofthecomplaintbytelephone?Date://Time:am/pm

Nameofthepersonwhomadethenotification:

Nameofthepersonyouspoketo(ifknown):

PrivacyTheSecretary totheDepartmentofEducationandTrainingiscommittedtoresponsibleandfairhandlingofpersonalinformation,consistentwiththeInformationPrivacyAct2001(Vic),theHealthRecordsAct2001(Vic)andotherstatutoryobligationsincludingobligationsundertheChildren’sServicesAct1996(Vic).TheDepartmentofEducation andTrainingmayneedtodiscloseyour personalinformationtootherStateandCommonwealthagenciestocheck orconfirm theinformationyouhaveprovided.Youcanrequestaccesstoorupdateyourpersonalinformationbycontactingus.Ourinformationprivacypolicyisavailableat

Complainantdetails

11.Name:

12.Phonenumber(ifnotanemployeeoftheservice):

13. / Thecomplainantisthe: / Parent/Guardianofachildattendingtheservice
Other(specify)

14. Details of the complaint

15.Howwasthecomplaintdealtwith-includedetailsofresponsetothecomplainantandanychangesmadetoattheserviceasofresultofthecomplaint(Ifmorespaceisrequired,pleaseattachanadditionalclearlylabelledpage)

Detailsofanychildreninvolved

Ifthenotificationrelatestothehealth,safetyorwellbeingofanychild(ren)beingcaredfororeducatedbytheservicepossiblybeingcompromisedpleasecompletethissection(ifmorespaceisrequired,pleaseattachanadditionalclearlylabelledpage)

FamilyName:

18.Whatwerethechild(ren)doingatthetime?

19.Wasthechild(ren)harmedinanyway?(pleaseprovidedetails)

20.Pleaseindicatewherethechild(ren)wereinjured(ifapplicable):

21.Whatactionsweretakenbytheservice?

Appliedfirstaid(providedetails)

Calledparents / Time: / am/pm
Other*(providedetails) / Time: / am/pm

*Ifemergencyserviceswererequired to attend orthechildrequired the attention ofa registered medicalpractitioner or admissiontohospital pleasecomplete theSeriousIncidentNotificationform

22.Arethechild(ren)stillattendingtheservice?

Yes

No (ifno,datechild(ren)withdrawn and why)//

Numbersofchildrenpresent

23.Howmanychildrenwerepresentintheareawheretheincidentoccurred?Under3Years:Over3years:

24.Howmanychildren werepresentintotalattheserviceatthetime?

Under3Years:Over3years:

Staffingdetails

25.Ifthecomplaintisaboutstaffmember(s)oftheservice,whatarethenamesofthosestaffmember(s)?

26.Whatarethename(s)ofallpersons*presentwhoobservedtheincident?(pleaseindicatewhichstaffmember(s)hadfirstaidtraining).

*Forthe purpose ofthis question,personsincludesstaffmembers,volunteersand anyother personwho observedtheincident.

27.Whatwerethestaffmember(s)whoobserved,orwereinvolvedin,theincidentdoingatthetime?

28.Whatarethenamesandqualificationsofthestaffmemberspresentattheserviceatthetime?(youmayattachacopyofthestaffroster).

Name / Qualification/s

29.Total numberofstaffmembers:Ofthesehowmanyarequalified*:

*for the purposesofthis questionqualified meansateachingstaffmember or a staffmember thathassuccessfullycompleted a 2yearfulltime, or parttime equivalent,postsecondaryearlychildhood qualification or for OSHC,apostsecondarychild care oryouthrecreationqualification approved bytheSecretary

Equipment

30.Detailsofanyproducts/structures/equipmentinvolved

31.Dateofthelastequipmentmaintenancecheckyouconducted(ifequipmentinvolved)://

Drawaplanindicatingwheretheeventoccurredandwherethechildrenandstaffmemberswerepositioned

Declarationandsignature

32.Ideclare/certifythat:

•theinformationinthiscomplaintnotificationandanyattachmentsaretrueandcorrect

Thefollowingpeoplecansignthisform:

•Theowneroftheservice

•Thelicenseerepresentative

•Theprimarynominee

SignaturePrintednamePositionDate

X

DETOfficeuseonly:

Received by:Received://

Wasthenotification totheDepartmentwithintheprescribedtimelinesYesNo