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HOME
About Us
Client Intake
Join Us
Report An Incident
Progress Notes
Request Forms
Participant Intake Form
Advocate or Support Person Request Form
Participant Risk Assessment Form
Feedback and Complaints Form
Job Candidate Interview Form
Medication Incident Report Form
Training Evaluation Form
Download Forms
Participant Documents
Policy Form
Upload Forms
Menu
Participant
Risk
Assessment
Form
PARTICIPANT DETAILS
Given name/s
Family name
Preferred name
Date of Birth
Address:
Phone number:
Email address
Preferred contact method
*
Phone
SMS
Email
Mail
Other
Other preferred contact method?
Participant Requirements / Preferences
Preferred communication mode and language
Cultural requirements
Religious/belief based requirements
Interests
Physical requirements
Known Medical Conditions or Allergies
Specify
Effect
Treatment
Emergency Contacts
Name
Phone:
Email address
CARER / GUARDIAN DETAILS
Family name
Given name/s
Email address
Phone number
Postal address
In-person contact
Persons involved in the risk assessment
Was the participant involved in the assessment?
Yes
No
Declined
Unable
Reason:
Reason:
Staff Involved
Yes
No
Others Involved
Yes
No
Daily Personal Activities – for participants living alone
Sole Support Worker
Yes
Participant preference
Other:
A Monitoring and Supervision Plan is required
Reason:
Other
Information Sharing and Privacy
Privacy Policy Explained
Yes
No
Comments / feedback:
Sharing information
Consent to share information documented
Other Provider/s
List:
Sharing information comments
Daily Personal Activities Support – for participants living alone
Tick all applicable risks
Personal contact
No regular face-to-face contact with other NDIS providers
Limited or irregular face-to-face contact with relatives, friends or other people
Physical Mobility
Relies on other people to be physically mobile or to facilitate their physical mobility
Uses equipment to enable them to be physically mobile or to facilitate their physical mobility.
Communication
Without the assistance of another person the participant has limited or no ability to communicate.
The participant uses equipment to enable or facilitate communication with others, including to enable or facilitate the use of a phone or other device.
Note: If supports will be delivered by a sole support worker, and any of the above risks apply, a Monitoring and Supervision Plan must be created.
To what degree does the participant rely on our services? Explain below
How would the participants’ health and safety be impacted if their service was disrupted?
Medical conditions and interventions
Fractures, cuts
Bruising, abrasions
Seizures
Respiratory conditions
Allergies
Skin conditions
Endocrine conditions
Diabetes
Sleep disorders
Constipation
Incontinence
Dementia
Obesity
Teeth and gum conditions
Night timechecking required
Missed appointments
Medication
Not taking medication
Decline to participate in medical examinations or procedures
Decline to follow medical advice
Infectious disease
Other (specify)
Personal care
Feeding
Toileting
Showering/ bathing
Dental hygiene
Shaving
Grooming
Other (specify)
Eating and drinking
Swallowing difficulty
Choking on food
Enteral feeds – plus oral intake
Enteral feeds - nil by mouth
Food allergies
Specialised diet
Texture modified diet
Thickened fluids
Overnight feeds required
Food refusal
Dehydration
Posture and positioning
Alertness
Modified utensils or equipment
Behaviour related to eating or drinking
Pica (eating non-food items)
Environment
Other (specify)
Accidental movement
Startle reflex
Panic behaviour
Grabbing, holding, leaning
Sudden body movements
Falling, tripping
Bumping, running
Other (specify)
Manual handling
Transfers
Mobility
Vehicle access
Moving in bed
Personal care tasks
Other (specify)
Environmental risks
Electrocution
Fire lighting, flammables
Smoking
Sharps/knives
Poisons
Water hazard/ bathing
Sun exposure
Absconding/ wandering
Traffic (roads and rail)
Travel (private/public transport)
Other (specify)
Mental health and wellbeing
Suicide risk
Self-harm/ self-injury
Mental health diagnosis
Self-neglect
Hoarding
Other (specify)
Financial risks
Low income
Limited understanding of money
Challenges developing and sticking to a budget
Vulnerable to financial exploitation
Losing wallet/ purse/ bag
Debt
Gambling
Other (specify)
Social risks
Exploitation
Unsafe sex
Physical abuse/ threats
Verbal abuse/ threats
Harassment/ stalking
Emotional abuse
Sexual abuse/ threats
Neglect
Use of projectiles or weapons
Property damage
Harm to animals
Domestic violence
Criminal/ illegal behaviour
Social isolation
Lack of informal supports
Strangers
Anti-social peers
Other housemates
Other visitors to home
Family and carers
Discrimination
Homelessness
Leaving care
Other (specify)
Substance use
Drugs
Medication misuse
Alcohol
Smoking
Other (specify)
Other
Monitoring and supervision plan
Is Personal Support (Assistance with Daily Personal Activities) being provided by a sole Worker?
Yes
No
If so, set out the frequency at which Enable, Independent Living, Housing and Support Services will undertake in-person supervision of the Worker. It could be weekly, monthly, bi-monthly, quarterly or six-monthly dependent on the individual circumstances.
If so, set out the frequency that will be used to engage with providers who may be involved in providing Other Support Services to the Client in their home or in supporting the Client to access community based activities.
RISK MANAGEMENT PLAN
Type of Risk
Participant
Others
Risk Treatment
Person Responsible
Review Date
Participant/Representative Name:
Participant/Representative Signature:
Date
Manager/Supervisor Name:
Manager/ Supervisor Signature:
Date
Risk Assessment Review
Date
Reason for Review
Scheduled Review
Feedback
Change in Participant Needs/ Circumstances
Outcome of Review and Actions to be Taken
Details:
New Risk Assessment completed
No Changes Required, Next Scheduled Review Date:
Review Completed By
Signature
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