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Notification (complaint)

Health Practitioner Regulation National Law (the National Law)

Please complete this form to make a notification about a health practitioner

or student: Aboriginal and Torres Strait Islander health practitioner, Chinese
medicine practitioner, chiropractor, dental hygienist, dental prosthetist, dental
therapist, dentist, doctor, nurse or midwife, medical radiation practitioner,
occupational therapist, optometrist, osteopath, pharmacist, physiotherapist,
podiatrist or psychologist.
If you need assistance to complete this form, phone the Australian Health
Practitioner Regulation Agency (AHPRA) on 1300 419 495 and ask to speak to
a Notifications Officer.
Health practitioners, employers and education providers
If you are a health practitioner, employer or education provider and are making
a mandatory notification as required under the National Law, please complete
this form and send it to AHPRA.

The Board and AHPRA are committed to protecting your personal information
in accordance with the Privacy Act 1988 (Cth). The ways the Board and AHPRA
may collect, use and disclose your information are set out in the collection
statement relevant to this application, available at
www.ahpra.gov.au/privacy.
By signing this form, you confirm that you have read the collection statement.
AHPRAs privacy policy explains how you may access and seek correction of
your personal information held by AHPRA and the Board, how to complain to
AHPRA about a breach of your privacy and how your complaint will be dealt
with. This policy can be accessed at www.ahpra.gov.au/privacy.

Symbols in this form

Additional information
Provides specific information about a question or section of the form.

FOR NOTIFICATIONS IN NEW SOUTH WALES (NSW)

Members of the public
To make a notification about the conduct, health or performance of a practitioner,
contact the NSW Health Care Complaints Commission on 1800 043 159
or (02) 9219 7444.
Health practitioners, employers and education providers
To make a mandatory notification relating to a registered practitioner
or student, complete this form and return it to AHPRA. In NSW, AHPRA will refer
the notification to the appropriate organisation.

FOR COMPLAINTS IN QUEENSLAND

In Queensland, concerns about the health, conduct and performance of health
practitioners are known as complaints, and these are received only by the
Office of the Health Ombudsman (OHO). The OHO assesses the severity of
all complaints and determines which complaints it must retain and manage,
and which complaints to refer to AHPRA to manage on behalf of the National
Boards.
For more information, or to make a complaint in Queensland visit the OHO
website at www.oho.qld.gov.au, or call the OHO on 133 646 (133 OHO)

Please post this form with

required attachments to:

Privacy and confidentiality

Attention
Highlights important information about the form.
Attach document(s) to this form
Processing cannot occur until all required documents are received.
Signature required
Requests appropriate parties to sign the form where indicated.

Completing this form

Read and complete all questions.
Ensure that all pages and required attachments are returned to AHPRA.
Use a black or blue pen only.
Print clearly in B L O C K

L E T T E RS

Place X in all applicable boxes:

AHPRA
GPO Box 9958
IN YOUR CAPITAL CITY (refer below)

You may contact AHPRA on

1300 419 495 or you can lodge an enquiry
at www.ahpra.gov.au

Sydney NSW 2001

Canberra ACT 2601

Melbourne VIC 3001

Brisbane QLD 4001

Adelaide SA 5001

Perth WA 6001

Hobart TAS 7001

Darwin NT 0801

Effective from: 13 November 2014

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SECTION A: Your details

1. Is your notification (or
complaint) about more
than one health
practitioner/student?
2. What is your role in this
notification?

YES

Complete a separate notification form for each health practitioner/student

NO

Your role in the notification

The patient

A health practitioner (specify profession below)

SPECIFY

A friend of the patient

If you are a colleague, please indicate your relationship

to the health practitioner/student:

Relative of the patient

Lawyer of the patient

Senior

Education provider

Peer

Junior

Other (specify below)

Employer of the health practitioner

3. What is your name and date

of birth?

SPECIFY

Title
MR

MRS

MISS

MS

DR

OTHER

SPECIFY

First given name

Family (legal) name

Date of birth

4. What are your contact details?

D D / MM / Y Y Y Y

Provide your current contact details below place an

next to your preferred contact phone number.

Mobile

Business hours

After hours

Email

5. What is your mailing address?

Site/building and/or position/department (if applicable)

Address/PO Box (e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET; or PO BOX 1234)

City/Suburb/Town

State or territory (e.g. VIC, ACT)/International province

Postcode/ZIP

Country (if other than Australia)

Effective from: 13 November 2014

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6. Who is the health practitioner/

student this notification is
about?

First given name

Middle name(s)

Family (legal) name

Previous names know by (optional)(e.g. Maiden name)

Profession/specialty (if known)(e.g. nurse, podiatrist)

Registration number (if known)

Place of employment (e.g. clinic, health service)

Site/building and/or position/department (if applicable)

Address (e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET)

City/Suburb/Town

State or territory (e.g. VIC, ACT)/International province

Postcode/ZIP

Country (if other than Australia)

7. If we need to speak to you,

YES
will you require an interpreter?

NO

Please tell us what language

8. Are you making this

notification on behalf of a
patient?

YES

Go to next question NO Go to Question 14

SECTION B: About the patient

9. Do you have the patients
consent or knowledge?

YES

NO

You may still make a notification without the patients consent or knowledge. It is preferable,
however, for you to inform the patient of your actions and request the patient to complete
Consent authorisation form A, attached to this form.

Effective from: 13 November 2014

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10. What is the patients name

and date of birth?

Title
MR

MRS

MISS

MS

DR

OTHER

SPECIFY

First given name

Middle name(s)

Family (legal) name

Date of birth

D D / MM / Y Y Y Y
11. What are the patients contact
details?

Provide your current contact details below place an

next to your preferred contact phone number.

Mobile

Business hours

After hours
Email

12. What is the patients address?

Site/Building (if applicable)

Address (e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET)

City/Suburb/Town

State or territory (e.g. VIC, ACT)/International province

Postcode/ZIP

Country (if other than Australia)

13. If we need to speak to the

patient will they require an
interpreter?

YES

NO

Please tell us what language

Effective from: 13 November 2014

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SECTION C: Mandatory notifications

14. Are you a health practitioner,
an educator, or an employer?

G
 o to next question NO G
 o to question 17

YES

15. Are you reporting notifiable

conduct about a health
practitioner or a student?

N
 otifiable conduct in relation to a registered health practitioner means the practitioner has:
(a) practised the practitioners profession while intoxicated by alcohol or drugs; or
(b) engaged in sexual misconduct in connection with the practice of the practitioners profession; or
(c) placed the public at risk of substantial harm in the practitioners practice of the profession because
the practitioner has an impairment; or
(d) placed the public at risk of harm because the practitioner has practised the profession in a way that
constitutes a significant departure from accepted professional standards.

NO
YES

G
 o to question 17

Please choose from below
Health practitioner
I have formed the reasonable belief that the practitioner has behaved in a way that
constitutes notifiable conduct as he/she has:

Please select:

practised the practitioners profession while intoxicated by alcohol or drugs

engaged in sexual misconduct in connection with the practice of the practitioners

profession

placed the public at risk of substantial harm in the practitioners practice of the
profession because the practitioner has an impairment, or

placed the public at risk of harm because the practitioner has practised the
profession in a way that constitutes a significant departure from accepted
professional standards.

16. How did the conduct come to

your attention?

S
 tudent
I have formed the reasonable belief that
the student this notification is about has an
impairment, that in the course of the student
undertaking clinical training may place the public
at substantial risk of harm.

Directly observed by me (e.g. as part of care team)

Via another person/word of mouth

 isclosed to me by the person this notification

D
is about

Record review, audit

Via patient(s)

Other (specify below)

SPECIFY

SECTION D: Your description of what happened and/or your concerns

17. On or between which dates(s)
did the conduct take place?

Estimated dates

18. Where did the event(s) take

place?

Mark all applicable

D D / M M / Y Y Y Y to D D / M M / Y Y Y Y

Hospital inpatient

Pharmacy

Hospital outpatient

Other (specify below)

Practitioners office/consulting rooms

Primary care facility
Patients home

19. How many patients were

affected by the conduct?

Number of patients affected

Dont know
0

2+ (please specify number of patients below)

SPECIFY

Effective from: 13 November 2014

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20. Were any patients harmed

by the conduct?

Mark all applicable

Dont know

Minor physical harm

No harm

Significant or major physical harm

L atent or potential harm (e.g. exposed to radiation,

risk of infection)

Death

Drug dependency

Other (specify below)

Minor psychological or emotional harm

Significant or major psychological or emotional harm

21. Please describe what happened

Please describe what happened or what you are concerned about, including the place, date and time the events occurred.
Where appropriate, please include details of the type of treatment involved, names and contact details of any witnesses.

Attach additional sheets if more space is required, with your name clearly marked on each page.

Effective from: 13 November 2014

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22. Do you have supporting

documentation (such as
reports from other health
practitioners or evidence of
medication dispensed) from
the event(s)?

YES

23. Have you discussed your

concerns directly with the
health practitioner/student?

YES

NO

Please attach all supporting documentation. This may include information, such as photographs,
reports, test results, retained medication or other evidence that may be pertinent which you feel
the Board might need when considering your concerns.
NO

Provide details of the result of your discussion below

24. Have you made a complaint

YES NO
to another organisation about
this matter?
Provide the name of the organisation and the date you lodged the complaint below
Name of organisation

Date lodged

D D / MM / Y Y Y Y
SECTION E: Authorisation

Before you sign and date this form: Make sure that you have answered all of the relevant questions correctly and read the statements
below. An incomplete form may delay processing and you may be asked to complete a new form.

Notifiers declaration To be completed by the notifier

I ask that AHPRA consider the issues described in this notification form.
I am aware that AHPRA may send this form and attachments to the health practitioner/student concerned.
I confirm that I have read the privacy and confidentiality statement for this form.
Name of notifier

Signature of notifier

SIGN HERE

Date

D D / MM / Y Y Y Y
25. Are you the patient?

YES
NO

Please sign Consent authorisation form A attached to this form

Choose option below, if applicable
 atient-nominated representative
P
If the patient is able to provide consent and wants you to represent him/her, please ask the patient
to complete and sign Consent authorisation form B attached to this form.
L egal representative of patient without capacity
If you are the legal representative of the patient who is without the capacity to make decisions, or is
deceased, please attach evidence of your position as the legal representative of the patient and sign Consent
authorisation form C attached to this form.

Effective from: 13 November 2014

Page 7 of 10

Consent authorisation form A

If you are the patient, please sign and complete this form.

I,

born on the

(your full name)

(day)

day of the

(month)

month

(year)

hereby consent for the Australian Health Practitioner Regulation Agency (AHPRA) and the relevant health practitioner Board, as
defined under the Health Practitioner Regulation National Law (the National Law), to be authorised to:
1. access information, including my health records, related to the notification to the Board
2. provide my health records and other relevant information to the practitioner who is the subject of the notification in order to
obtain a response
3. provide my health records and other relevant information to another entity if the Board decides to refer the matter to another
entity under the National Law, and
4. provide my health records and other relevant information to any necessary experts in order to obtain independent opinions in
relation to the notification and associated issues.

Print your name:

Your signature:

SIGN HERE

Date:

D D / MM / Y Y Y Y

Notifications number:
OFFICE USE ONLY
NOTF-00

Effective from: 13 November 2014

Consent authorisation form B

If you are the patient and you want the person nominated below to represent you,
please sign and complete this form.
I,

born on the

(your full name)

(day)

day of the

(month)

month

(year)

1. appoint the person nominated below as my representative to lodge this notification on my behalf
2. authorise the Australian Health Practitioner Regulation Agency (AHPRA) to release my health records, if required, related to
the notification to my representative
3. authorise AHPRA to address all correspondence relating to the notification to my representative and to release any
information relating to the notification to my representative
4. hereby consent for AHPRA and the relevant health practitioner Board, as defined under the Health Practitioner Regulation
National Law (the National Law), to be authorised to:
access information, including my health records, related to the notification to the Board
provide my health records and other relevant information to the practitioner who is the subject of the notification in order
to obtain a response
provide my health records and other relevant information to another entity if the Board decides to refer the matter to
another entity under the National Law, and
provide my health records and other relevant information to any necessary experts in order to obtain independent
opinions in relation to the notification and associated issues.

Name of patient
Signature of patient

SIGN HERE

Date

D D / MM / Y Y Y Y

Name of representative
Signature of representative

SIGN HERE

Date

D D / MM / Y Y Y Y

Notifications number:
OFFICE USE ONLY
NOTF-00

Effective from: 13 November 2014

Consent authorisation form C

If you are the patients legal representative because the patient does not have the
capacity to make decisions, or the patient is deceased, please sign and complete this
form.
I,

(your full name)

(patients full name)

am the legal representative of

born on the

(day)

day of the

(month)

month

(year)

and hereby consent for the Australian Health Practitioner Regulation Agency (AHPRA) and the relevant health practitioner Board,
as defined under the Health Practitioner Regulation National Law (the National Law), to be authorised to:
1. access information, including the patients health records, related to the notification
2. provide the patients health records and other relevant information to the practitioner who is the subject of the notification in
order to obtain a response
3. provide the patients records and other relevant information to another entity if the Board decides to refer the matter to
another entity under the National Law, and
4. provide the patients records and other relevant information to any necessary experts in order to obtain independent opinions
in relation to the notification and associated issues.

Where the patient does not have the capacity to sign, or where a patient is deceased, please attach evidence of your
position as the authorised legal representative of the patient.
Print your name
Your signature

SIGN HERE

Date

D D / MM / Y Y Y Y

Notifications number:
OFFICE USE ONLY
NOTF-00

Effective from: 13 November 2014