Forms for residential service operators

Use these forms to meet your obligations as a residential service provider under the Residential Services (Accreditation) Act 2002 (the Act).

Registration and accreditation

• Form 1 and notes – Application for registration of a residential service (PDF, 332KB)
  The service provider completes this form to register the residential service.

• Form 2 and notes – Application for accreditation of a residential service (PDF, 294KB)
  The service provider completes this form to apply for the accreditation of a residential service.

• Form 3 and notes – Application for renewal of accreditation of a residential service (PDF, 286KB)
  The service provider completes this form to apply for a renewal of accreditation of a residential service, this form must be completed before the accreditation expires, but not more than 3 months before the expiry date.

• Form 4 and notes – Application to become a registered service provider of a currently registered residential service (change of service provider) (PDF, 375KB)
  This form must be completed when the following changes occur with a residential service:
  • the premises is sold and the service is continuing with a new service provider
  • a new service provider joins with the current service provider
  • there are a number of service providers and one is no longer involved in the operation of the residential service.

Notification of changes

• Form 6 and notes – Notification of commencement of an associate (PDF, 227KB)
  This form must be completed when there is a change of an associate of an existing residential service. An associate is described as an executive officer of the corporation listed as the service provider who takes part in the management of the service. An associate is also an individual who makes decisions that influence the operation of the service or the health, safety or other interests of residents in the service on behalf of the service provider.


• Form 7 and notes – Notification of other changes (PDF, 346KB)
  Use this form to notify about other changes, as required under sections 64, 67 and 69 of the Act. This includes any matter that may be relevant to the continued registration of the residential service.


• Form 8 and notes – Notification of a death of a resident (PDF, 300KB)
  Service providers must complete this form to notify the chief executive within 7 days of the death of a resident in a level 3 service.

Applications for review of decision

• Form 5 – Application for review of decision (PDF, 112KB)
  If you disagree with a 'reviewable decision' of the chief executive under the Act you can complete this form within 28 days the decision made.


• Application for review of decision – Fair Trading Inspectors Act 2014, section 74 (PDF, 208KB)
  Use this form to apply for a review of a decision about seizure or forfeiture to the state of a thing made by a Fair Trading Inspector.

Medications

• Written request/consent for assistance with medication (PDF, 127KB)
  Service providers must ensure they obtain an initial request (in writing) from the person requiring assistance with their medication. Alternatively, if a person requiring assistance has impaired decision-making capacity, a substitute decision maker as defined under the Powers of Attorney Act 1998 and Guardianship and Administration Act 2000 may request assistance in writing on behalf of the resident.


• Medication record (PDF, 170KB)
  Service providers must keep a record of the daily living, medical or health supports required by each resident. A medication record must accurately reflect the medication assistance provided to residents


• Medication distribution record (PDF, 193KB)
  A medication distribution record should be used for accurate and timely recording of each occasion where medication assistance is provided.


• Staff training record (PDF, 143KB)
  Training records must be maintained for all staff. You must ensure that staff are given training in the policies and procedures for assisting with medication, obtaining and storing medication, familiarisation with packaging and labelling, and the completion of medication records.


• Medication incident report form (PDF, 122KB)
  A medication incident is any preventable event that may lead to inappropriate medication use or result in harm from medications, and may include a mistake with medication, or a problem that could cause a mistake with medication.
  
  As soon as possible after an incident, but no later than by the end of the shift, all medication incidents must be recorded on a medication incident report form.


• Medication record (temporarily off-site) (PDF, 171KB)
  This record should be used to document each occasion where medication is provided for the resident to use when off-site (e.g. a social outing).


• Medication assistance compliance checklist (PDF, 176KB)
  This checklist can help you identify areas needing attention to ensure service providers are appropriately assisting residents with medication. It is recommended service providers complete the checklist to assess compliance prior to any accreditation or renewal audit.