Notification Form - Part A€¦ · 2.7 Employment status with agency at the time the allegation was...
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1 NSW Ombudsman Disability Reportable Incidents Division – Notification Form Part A3 – Employee to client incident – December 2015 Notification Form - Part A Employee to Client Incident What is an employee to client incident? An employee to client incident involves any of the following in connection with an employee of the Department of Family and Community Services (FACS) or a funded provider and a person with disability living in supported group accommodation: i) any sexual offence committed against, with, or in the presence of the person with disability, ii) sexual misconduct committed against, with, or in the presence of the person with disability, including grooming of the person for sexual activity, iii) an assault of the person with disability, not including the use of physical force that, in all the circumstances, is trivial or negligible (but only if the matter is to be investigated under workplace employment procedures), iv) an offence under Part 4AA (Fraud) of the Crimes Act 1900 committed against the person with disability, v) ill-treatment or neglect of the person with disability. Instructions for completing and sending the notification form to the Ombudsman This form is to be used to notify the Ombudsman’s Office of a reportable incident in disability supported group accommodation. This is a pdf template and does not save automatically. To save the document use ‘save as’ and place on your system before completing. Note: The text boxes are a fixed size. If additional space is required, please attach separately with the form. Part A of the notification form, relating to the details of the people involved, the allegation and the agency’s initial response, is to be sent to the Ombudsman’s office within 30 days of the head of FACS or a funded provider becoming aware of the reportable incident. Please provide relevant supporting documentation including incident reports, any risk assessment and where relevant, lifestyle plans and behaviour support plans. Once your agency has completed an investigation into the reportable allegation, and you have finalised your risk management response, please also complete Part B of the notification form. If you require assistance, please contact the Ombudsman’s Disability Reportable Incidents Division on 02 9286 1000. Delivery instructions To maintain a high level of confidentiality, please send the notification form and any other documents relating to the investigation to the Ombudsman by: • registered mail • hand delivery, or • courier Addressed to: Attention – Disability Reportable Incidents Division NSW Ombudsman Level 24, 580 George Street Sydney NSW 2000 A3
Transcript of Notification Form - Part A€¦ · 2.7 Employment status with agency at the time the allegation was...
1NSW Ombudsman Disability Reportable Incidents Division – Notification Form Part A3 – Employee to client incident – December 2015
Notification Form - Part A
Employee to Client Incident
What is an employee to client incident?An employee to client incident involves any of the following in connection with an employee of the Department of Family and Community Services (FACS) or a funded provider and a person with disability living in supported group accommodation:
i) any sexual offence committed against, with, or in the presence of the person with disability,ii) sexual misconduct committed against, with, or in the presence of the person with disability, including
grooming of the person for sexual activity,iii) an assault of the person with disability, not including the use of physical force that, in all the circumstances,
is trivial or negligible (but only if the matter is to be investigated under workplace employment procedures),iv) an offence under Part 4AA (Fraud) of the Crimes Act 1900 committed against the person with disability,v) ill-treatment or neglect of the person with disability.
Instructions for completing and sending the notification form to the OmbudsmanThis form is to be used to notify the Ombudsman’s Office of a reportable incident in disability supported group accommodation.
This is a pdf template and does not save automatically. To save the document use ‘save as’ and place on your system before completing.
Note: The text boxes are a fixed size. If additional space is required, please attach separately with the form.
Part A of the notification form, relating to the details of the people involved, the allegation and the agency’s initial response, is to be sent to the Ombudsman’s office within 30 days of the head of FACS or a funded provider becoming aware of the reportable incident. Please provide relevant supporting documentation including incident reports, any risk assessment and where relevant, lifestyle plans and behaviour support plans.
Once your agency has completed an investigation into the reportable allegation, and you have finalised your risk management response, please also complete Part B of the notification form.
If you require assistance, please contact the Ombudsman’s Disability Reportable Incidents Division on 02 9286 1000.
Delivery instructionsTo maintain a high level of confidentiality, please send the notification form and any other documents relating to the investigation to the Ombudsman by:
• registered mail
• hand delivery, or
• courier
Addressed to:
Attention – Disability Reportable Incidents Division NSW Ombudsman Level 24, 580 George Street Sydney NSW 2000
A3
2 NSW Ombudsman Disability Reportable Incidents Division – Notification Form Part A3 – Employee to client incident – December 2015
1. Agency details1.1 Name of agency:
1.2 Head of agency:
1.3 Position title:
1.4 Signature:
1.5 Date:
1.6 Agency contact details:
Postal address: (not a home address)
Telephone: Email:
1.7 Your case/reference number (if known):
1.8 If this notification relates to any other notification(s) or inquiries made to the Ombudsman, provide our reference number(s) or other details:
1.9 Agency type:
Department of Family and Community Services
Non-government funded provider
Other public authority
1.10 Does your agency receive funding under the Disability Inclusion Act 2014?
No Yes
1.11 Does your agency provide services to children (ie. clients under 18 years)?
No Yes
If another officer is preferred as the contact person regarding this notification provide their details below:
1.12 Contact officer:
1.13 Position title:
1.14 Contact details (if different from above):
Postal address: (not a home address)
Telephone: Email:
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2. Details of employee subject of allegationThis section needs to be completed for each employee who is the subject of allegation.
2.1 Does this notification contain allegations against more than one employee?
No Yes, how many?
2.2 Given names:
Family name:
2.3 Gender: Male Female Transgender Intersex
2.4 Date of birth:
2.5 Position with agency at the time the agency became aware of the allegation:
2.6 Address of employment at time of incident:
2.7 Employment status with agency at the time the allegation was made:
Employed
Permanent – full time Permanent – part time
Temporary – full time Temporary – part time Casual
OR
Engaged
Contracted labour hire staff
Volunteer
Contractor
Other (state)
2.8 Date employee commenced service with your Agency:
2.9 Date of most recent employee Criminal Records Check:
2.10 Working with Children Check clearance number (if applicable):
2.11 Is the employee aware that an allegation has been made against them?
Note: It is important to recognise that in some cases – particularly in matters that involve criminal allegations – the employee should not be advised unless and until police have authorised this to take place.
Yes – Date informed:
Who informed them:
Your agency
NSW Police Force
FACS
Unknown
Other (provide details)
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Is the employee aware of:
Details of the reportable allegation
Type of reportable allegation only
Only that there has been a reportable allegation - not the type
No (reason):
Police advice
FACS advice
Unable to contact employee
Need to make further inquiries
May compromise investigation
Unknown
2.12 Have prior allegations been made against the employee in relation to abuse or neglect of a person with disability?[The NSW Ombudsman publication ‘Guide for services: Reportable incidents in disability supported group accommodation’ sets out the various categories of mistreatment and defines serious neglect.]
No
Yes (specify):
Please provide details of all prior allegation/s against the employee
Have findings been made against the employee regarding prior allegations of abuse or neglect of a person with a disability following investigation?
No
Yes (specify):
Please provide details of previous findings against the employee
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What, if any, management action was taken against the employee following previous investigation/s?
Changed duties
Monitoring
Training
No action
Other
Please provide details of management action taken against the employee
3. Details of the alleged victim/s Only provide information about an alleged victim who is a person with disability living in supported group accommodation. If more than one alleged victim is involved, please complete this section of the form for each person. If there are more than 3 clients involved, please fill in another form.
3.1 Does this notification involve more than one alleged victim?
No Yes, how many? Unknown
CLIENT ONE:
3.2 Given names:
Family name:
3.3 Gender: Male Female Transgender Intersex
3.4 Date of birth:
3.5 Age of the client at the time of the reportable incident:
3.6. Name and address of supported accommodation:
3.7 Length of time residing at supported accommodation:
3.8 Number of other residents, if known:
3.9 Type of residence
Group home Residential facility Respite
Other (specify):
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3.10 Is the client receiving NDIS funding? No Yes
3.11 Details of the client’s disability:
Autism spectrum
Developmental delay (up to age 6)
Intellectual impairment (specify): Mild Moderate Severe Profound Unknown
Other cognitive impairment
Mental Health
Neurological impairment
Physical impairment
Sensory impairment
Other (specify):
Unknown
3.12 Does the client have behaviour support needs?
Absconding
Eating non-food items
Other behaviour
Property destruction
Self-harm
Violence towards others
Other (specify):
3.13 How does the person communicate?
Verbal communication
Adjusted verbal language – such as the use of selected words or sound
Electronic communication
Picture communication
Sign language
Other signing
Other – such as use of gestures
3.14 Is the alleged victim:
Aboriginal and/or Torres Strait Islander No Yes Unknown
Of culturally and linguistically diverse (CALD) background No Yes Unknown
3.15 Is a guardian appointed?
No Yes, Public Yes, Private
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Functions of the guardianship order:
Accommodation Medical dental
Health care services Restrictive practices Advocacy
Other (specify):
3.16 Does the person receive informal decision making support from family/friends/advocate? No Yes
3.17 If the alleged victim is a child, is parental responsibility for the child with the Minister for Family and Community Services?
Yes Shared responsibility No
CLIENT TWO:
3.2 Given names:
Family name:
3.3 Gender: Male Female Transgender Intersex
3.4 Date of birth:
3.5 Age of the client at the time of the reportable incident:
3.6. Name and address of supported accommodation:
3.7 Length of time residing at supported accommodation:
3.8 Number of other residents, if known:
3.9 Type of residence
Group home Residential facility Respite
Other (specify):
3.10 Is the client receiving NDIS funding? No Yes
3.11 Details of the client’s disability:
Autism spectrum
Developmental delay (up to age 6)
Intellectual impairment (specify): Mild Moderate Severe Profound Unknown
Other cognitive impairment
Mental Health
Neurological impairment
Physical impairment
Sensory impairment
Other (specify):
Unknown
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3.12 Does the client have behaviour support needs?
Absconding
Eating non-food items
Other behaviour
Property destruction
Self-harm
Violence towards others
Other (specify):
3.13 How does the person communicate?
Verbal communication
Adjusted verbal language – such as the use of selected words or sound
Electronic communication
Picture communication
Sign language
Other signing
Other – such as use of gestures
3.14 Is the alleged victim:
Aboriginal and/or Torres Strait Islander No Yes Unknown
Of culturally and linguistically diverse (CALD) background No Yes Unknown
3.15 Is a guardian appointed?
No Yes, Public Yes, Private
Functions of the guardianship order:
Accommodation Medical dental
Health care services Restrictive practices Advocacy
Other (specify):
3.16 Does the person receive informal decision making support from family/friends/advocate? No Yes
3.17 If the alleged victim is a child, is parental responsibility for the child with the Minister for Family and Community Services?
Yes Shared responsibility No
CLIENT THREE:
3.2 Given names:
Family name:
3.3 Gender: Male Female Transgender Intersex
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3.4 Date of birth:
3.5 Age of the client at the time of the reportable incident:
3.6. Name and address of supported accommodation:
3.7 Length of time residing at supported accommodation:
3.8 Number of other residents, if known:
3.9 Type of residence
Group home Residential facility Respite
Other (specify):
3.10 Is the client receiving NDIS funding? No Yes
3.11 Details of the client’s disability:
Autism spectrum
Developmental delay (up to age 6)
Intellectual impairment (specify): Mild Moderate Severe Profound Unknown
Other cognitive impairment
Mental Health
Neurological impairment
Physical impairment
Sensory impairment
Other (specify):
Unknown
3.12 Does the client have behaviour support needs?
Absconding
Eating non-food items
Other behaviour
Property destruction
Self-harm
Violence towards others
Other (specify):
3.13 How does the person communicate?
Verbal communication
Adjusted verbal language – such as the use of selected words or sound
Electronic communication
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Picture communication
Sign language
Other signing
Other – such as use of gestures
3.14 Is the alleged victim:
Aboriginal and/or Torres Strait Islander No Yes Unknown
Of culturally and linguistically diverse (CALD) background No Yes Unknown
3.15 Is a guardian appointed?
No Yes, Public Yes, Private
Functions of the guardianship order:
Accommodation Medical dental
Health care services Restrictive practices Advocacy
Other (specify):
3.16 Does the person receive informal decision making support from family/friends/advocate? No Yes
3.17 If the alleged victim is a child, is parental responsibility for the child with the Minister for Family and Community Services?
Yes Shared responsibility No
4. Details of the reportable allegation/s4.1 Does this notification concern more than one reportable allegation?
No Yes, how many?
4.2 Date of alleged incident, if known:
Or period from: to
4.3 Date your head of agency became aware of the allegation/s:
4.4 Location where reportable incident occurred (if different to residential address above):
Group home
Residential facility
Respite — flexible
Respite — centre-based
Day program
Other (specify):
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4.5 Description of each reportable allegation
Please provide details of each of the reportable allegations
4.6 Name and role of the first person who became aware of the incident/allegation:
4.7 Name and role of person who reported the incident/allegation to the head of agency:
4.8 Type of employee to client reportable incident[For further information, please see the Guide for services: Reportable incidents in disability supported accommodation on the NSW Ombudsman website: www.ombo.nsw.gov.au.]
Sexual offence
Sexual assault
Aggravated sexual assault
Sexual intercourse with a 16-17 year old in the context of a ‘special care relationship’
Indecent assault
Act of indecency
Production, dissemination or possession of child pornography
Procuring or grooming children under the age of 16 years for unlawful sexual activity
Carer or exploitation offence under section 66F the Crimes Act 1900[Section 66F of the Crimes Act 1900 is designed to prevent the sexual exploitation of people with a cognitive impairment by their carers, or by anyone else who has knowledge of the person’s impairment and enters into a sexual relationship with the intent of taking advantage. Irrespective of the consent of a person, the Crimes Act prohibits sexual intercourse in the following circumstances:• between a person with a cognitive impairment and a person who is responsible for the care of that person (the “carer’s
offence”; s.66F(2))• between a person with a cognitive impairment and any other person who has the intention of taking advantage of that
person’s cognitive impairment (the “exploitation offence”; s.66F(3))]
Sexual misconduct
Crossing professional boundaries
Sexually explicit comments and other overtly sexual behaviour
Grooming behaviour
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Physical assault
Hitting/kicking/punching
Pushing/shoving/grabbing/throwing a person with disability
Inappropriate restraint/excess use of force
Use of object [Use of object includes the use of an implement or throwing an object towards a person with disability.]
Perceived threat of harm
Other deliberate/hostile/reckless application of force
Fraud
Fraud
[Where there is an allegation that a person, by any deception, dishonestly obtains property belonging to a person with disability, or dishonestly obtains a financial advantage or causes deliberately financial disadvantage to a person with disability.]
Intention to defraud by destroying or concealing accounting records
Intention to defraud by false or misleading statement
Intention by an officer of an organisation to deceive members of creditors by a false or misleading statement
Ill-treatment
Behaviour management that is seriously inappropriate/improper or is an unauthorised restricted practice
Making excessive or degrading demands of a person with disability
Hostile use of force
Other (specify):
Neglect
Clothing/food
Medical care
Shelter
Supervisory neglect
Failure to protect from abuse
Reckless act/failure to act
Other (specify):
Contravention of an apprehended violence order[This category relates to an incident occurring in supported group accommodation and involving a contravention by an employee of FACS or a funded provider of an AVO made for the protection of a person with a disability in supported group accommodation.]
Reportable conviction [This category is only applicable when a matter has been proven at court.]
Sexual offence
Physical assault
Fraud
Contravention of an apprehended violence order
Other (specify):
13NSW Ombudsman Disability Reportable Incidents Division – Notification Form Part A3 – Employee to client incident – December 2015
5. Interim action taken or proposed by agency5.1 Did your agency undertake a risk assessment when the allegation was made?
Yes, please provide a copy of the risk assessment
No, please provide reasons:
5.2 What action has been taken/proposed in respect to the employee while the reportable allegation is being investigated?
Increased supervision
Restriction on current duties
Transferred to alternative duties
Suspended with pay
Suspended without pay
Not re-engaged
Dismissed
Allowed to resign
Agency advised Office of the Children’s Guardian (OCG) of the interim risk[Agencies may provide information to the Office of the Children’s Guardian (OCG) under Chapter 16A of the Children and Young Person’s (Care and Protection) Act 1998 if the investigation/disciplinary proceeding has not been completed and the information relates to the safety, welfare or wellbeing of a particular child or young person or class of children if the provider reasonably believes that the provision of the information would assist the recipient to commence an investigation, provide a service, or manage the risk to children.]
Interim bar by the OCG
Final bar by the OCG [Tick one of these boxes if the OCG has advised you that the employee is subject to a bar or interim bar. This means that
they cannot be engaged or remain in child related work.]
No action
Please provide details of interim action taken or to be taken (including date action was/will be taken, duration of interim action and details of the specific action taken)
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5.3 Has the NSW Police Force been informed of the allegation?Agencies must report allegations of a criminal nature to the NSW Police Force. The main purpose of a police investigation is to make inquiries to determine whether there is sufficient evidence to charge a person with a criminal offence. Advice should be obtained from the NSW Police Force before commencing an investigation.
No
Yes, please provide:
Date of report to police:
Police event number:
Police Local Area Command reported to:
Name of investigator reported to:
Please provide details of referral to NSW Police, advice from police about the investigation, and current status of the police investigation
5.4 Is the NSW Police Force investigating the allegation?
No Yes Unknown
For matters referred to NSW Police Force, your Agency will need to obtain police clearance prior to continuing with your workplace investigation.
5.5 Has support been offered/ provided to the employee?
No (specify):
Yes (provide reasons)
5.6 What action has been taken or is proposed for the alleged victim/s while the incident/allegation is being investigated?
Review of staffing/supervision
Increased supervision
Review of and/or change in accommodation arrangements
Review of and/or change to behaviour support needs
Review of medical/health needs
Change in health support provided
Review of psychological/mental health needs
Change in psychological/mental health support provided
Education for client/s
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Training for staff
Review of legal/ decision-making capacity
Referral/assistance to access legal support
Referral/assistance to access a support person
Other (specify):
No action (state the reason):
Please specify the details of all action taken or proposed for the alleged victim/s
5.7 Has support been offered/provided to the alleged victim?
No, why not?
Yes, what kind?
5.8 Are the client’s family or guardian aware of the allegations? [Consent should be sought from adult clients (AV and/or SOA) before informing guardians, families and other supporters
of the allegation of abuse or neglect. Where the client has provided consent (or they are unable to provide informed consent), their guardian, family and/or key supporter should be informed of the allegation as soon as possible after the report is made. For children, their parent or guardian should generally be advised unless there are compelling reasons for believing that by providing a parent or guardian with advice about an allegation the client will be exposed to harm. In these circumstances, you should consult an expert e.g. police or FACS child protection services.]
No, why?
Not applicable, why?
Yes
5.9 If the allegation relates to a child:
Has the FACS Child Protection Helpline been informed of the reportable allegation?[Agencies must report suspected risk of significant harm to children to the FACS Child Protection Helpline. The main purpose of a FACS investigation is to identify whether a child is at risk of significant harm and whether any care and support issues exist. Advice should be obtained from FACS before commencing an investigation.]
No
Not applicable, why?
Yes, please provide:
Date of report:
Reference number:
Community Service Centre:
Is FACS investigating the reportable allegation? No Yes Unknown
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6. Documents attachedThe Ombudsman requires a copy of all materials which were considered by your agency during the investigation into the reportable incident. Please attach copies of any relevant documents. This may include, but is not limited to, the following:
Information about the reportable allegation/incident
Incident report/s
Medical reports
Communication profile
Information related to referral to NSW Police
Progress and routine notes
Correspondence regarding reportable allegation
Rosters related to the period of the allegation/incident
Relevant workplace policies and procedures
AVO
Agency documentation related to the AVO (eg. staff advice and guidance re. compliance with AVO)
Information about each client who is an alleged victim
Lifestyle or individual plan
Client risk plan
Health care plan, health care profile and any specific health support plans
Behaviour support plan
Restrictive practice authorisation
Capacity assessment
Consents
Transition plans
Information about each employee who is the subject of allegation
Prior allegations related to the abuse and neglect of a person with disability
Prior findings and management action in workplace investigations
Information about any interim action
Risk assessments and risk management action
Changes – interim or permanent - in staffing arrangements
Suspension or dismissal of employee who is the subject of allegation
Any other interim action taken including change in accommodation arrangements/support
Any other relevant materials
