Client to complete while exiting the program

Njernda Aboriginal Corporation is committed to providing high quality care and services and meeting your needs. We value your feedback so that we can ensure we are meeting your individual needs and are providing you with all the information you need. Please let us know what we do well and where we can improve our services.

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* 1. Do you wish to remain anonymous?

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* 2. If NO to Q1 please provide the information requested below?

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* 3. Are you providing feedback on another persons behalf?

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* 4. If YES please provide details.

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* 5. Are you the legal representative? ( Parent, Carer or Guardian of the person you are acting on behalf of in Q4)

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* 6. Does the person of Q4 know you are providing feedback on their behalf?

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* 7. Are we able to speak with the person who received the service?

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* 8. Were you satisfied with the quality of service you received and the choices you were offered?

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* 9. Were you satisfied that your privacy and dignity were maintained?

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* 10. Was the feedback and complaints process properly explained to you so that you felt that you knew what to do if you wanted to make a complaint or compliment?

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* 11. If you were referred to another service were you satisfied with the referral process?

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* 12. Did the staff member spend the right amount of time with you?

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* 13. Were you satisfied with the support plan put in place?

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* 14. Was your support plan revived and if need updated?

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* 15. If you were unhappy with a suggested plan or activity did you feel that you opinion was respected?

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* 16. Do you need help to establish to maintain links with the following?

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* 17. Were you supported to develop and maintain independence and life skills?

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* 18. Do you need more support before exiting this program?

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* 19. Do you need information on how to reengage with this service before you exit?

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* 20. Please provide addition details or feedback if needed.

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* 21. Have you discussed your concerns with the service provider with assistance with these concerns?

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* 22. If YES, with whom and what was the outcome?

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* 23. What would you like to happen as a result of providing this feedback?

Njernda Aboriginal corporation is committed to protecting your privacy. We collect and handle personal information that you provide on this feedback form for the purpose of investing and responding.
Njernda will only use your information in accordance with relevant privacy and other laws. in order for us to provide services to you, affectively and efficiently we may need to she your information with other staff members who deal with the matters identified in your feed back. if you choose to remain anonymous Njernda may be unable yo deliver the full rang if services you require. If you wish to contact the manger who is responsible for managing the personal information you provide on this form, please call 03 5480 6252 and ask for the manager of the department your services are delivered from.
Your also have the right to access your information and seek its correction under the Freedom of Information act 1982. For information about making a Freedom of Information application contact your manger or case worker on 03 5480 6252.

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* 24. I declare that this information is true and correct.

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* 25. Please Date

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Thank you for taking the time to provide feedback about our service.

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