OAPL Clinical Services - Complaint Reporting and Resolution Form

My complaint concerns: *

Oh dear! This form is for recording issues related to our clinical services only.

If you'd still like to submit this form, we'll forward your concerns on to OPC Health (our distribution business) for investigation.

Alternatively, you can contact sales@opchealth.com.au directly to address your product concerns and discuss your options.

Name of Person Completing this Form *

Phone number for follow-up contact *

Email for follow-up contact *

Format of complaint (if provided in written form separate to this from)

Date of complaint *

Time of of complaint

Location of complaint (use drop down menu or start typing....) *

Was a staff member involved? *

YESNO

Staff Member/s Involved *

Was a client or clients involved? *

YESNO

Name of client or clients involved *

Was a third party involved? *

YESNO

Name of third party/parties involved *

Where there any witnesses involved? *

YESNO

Witness contact information *

Description of complaint - provide as much detail as possible *

Photographic Evidence Upload

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Would you like to be contacted about this complaint to work on a solution together? Clicking YES will ensure your location's clinical manager makes contact with you *

YESNO

First Line investigation Record

Name of person completing first line investigation *

Is this complaint relevant to clinical services? *

Yes, clinical servicesNo, should be handled by another department

Enter the email and/or person the complaint was forwarded to for resolution

Origin of complaint *

Internal - complaint recorded by client using internal processExternal - complaint originated via external body (lodgement in system by OAPL staff)

Email of person completing investigation *

First line investigation of complaint - describe actions taken *

First line resolution of complaint - provide detail *

Please categorise cause of complaint *

Is a refund requested? *

YesNo

Authorisation is required for refunds

Refunds are only available for the cost of device.
Refunds are only available if the device is returned - no refunds on retained devices.
Refunds are not available for clinical time.

Please fill in request for refund form and forward to your approvals manager for authorisation:

https://opedah.sharepoint.com/:w:/r/sites/ClinicalServices/Shared%20Documents/Orthotics/OAPL%20Refund%20form.docx?d=wd0c050092361483a8571a0786c964aef&csf=1&web=1&e=XpwmZB%20

Approved refunds are to be emailed to Accounts.receiveable@oapl.com.au for processing.

Are changes to practice required? *

YES NO

Provide detail of practice change required

Date implemented *

Signature of Person Completing the Form *

Draw signature|Type signatureClear

Date:

Internal complaint satisfactorily resolved? *

YESNO

Escalation to Review Panel Action Record

Panel member/s involved in escalation investigation *

Escalation panel discussion meeting details *

Minutes completed by: *

Complainant meeting details *

Resolution of complaint *

Changes to OAPL practices required as a result of this resolution *

Changes for complainant to enact as a result of this resolution *

Escalated complaint resolved? *

YESNO

Choose Client Funding Body *

NDIS Quality and Safeguards Commission For Participants -

Make a Complaint | NDIS Quality and Safeguards Commission (ndiscommission.gov.au)

Ph: 1800035544

Aged Care Quality and Safety Commission Complaints & concerns

Aged Care Quality and Safety Commission

Ph: 1800951822

Victorian Health Complaints Commission - https://hcc.vic.gov.au/make-complaint - Ph: 1300582113

New South Wales Health Complaints Commission - Health Care Complaints Commission (nsw.gov.au) - Ph: 1800043159

Queensland Office of the Health Ombudsman Make a complaint - Office of the Health Ombudsman (oho.qld.gov.au) Ph: 133646

Tasmanian Health Complaints Commissioner Health Complaints Commissioner Tasmania Ph: 1800001170

SA Health and Community Services Complaints Commissioner Make a Complaint - HCSCC Ph: 1800232007

WA Health and Disability Services Complaints Office Health and Disability Services Complaints Office - Make a Complaint (hadsco.wa.gov.au) Ph: 1800813583

ACT Health Public Health Complaints | Health (act.gov.au) Ph: 02 51244444

NT Health Complaints Coordinator Patient complaint and compliment form | NT Health Ph: 08 89228824

If the complainant has been involved in the resolution, do they agree with the outcome reached? *

YESNO

Has the complainant requested a written outcome report? *

YESNO

External complaint resolved? (End of process) *

YESNO

Manager Signature *

Date internal resolution process completed *

Date external complaint resolved *

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