Make a complaint about a health service

Consent*

I consent to the Commission accessing, using and disclosing personal information and any health records relevant to this complaint. I understand that:
• if I have appointed a person to make the complaint on my behalf, the Commission will communicate and correspond with that person;
• the Commission may release to the person or organisation complained about, and other people dealing with this complaint, a copy of my complaint, personal information and health records;
• persons or organisations complained about may share relevant information with their insurers or legal advisers; and
• under the Human Rights Commission Act 2005, if a complaint relates to services provided by a registered health professional, the Health Services Commissioner must send the complaint, and all subsequent information obtained, to the relevant National Board for the various health professions. Where a complaint is referred to a National Board, the matter will be jointly considered by the Commissioner and the relevant Board prior to closure of the complaint.

I consent*

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile

Home Phone

Email

Date of birth

I am a person of Aboriginal descent (optional)
I am a person of Torres Strait Islander descent (optional)
I am a person with a disability (optional)

How would you prefer to be contacted?

Phone
Email
Post

Do you require assistance to participate in the complaints process?

Yes
No

Please explain the type of assistance you need

Are you making this complaint on behalf of someone else?

Yes
No

The first name of the aggrieved person (required)

The last name of the aggrieved person (required)

Date of birth of aggrieved person

Your relationship to the aggrieved person (choose from)

Parent or guardian of a person under 18 years old
Appointed to make the complaint on behalf of the person
Appointed as a guardian to act on behalf of the person (please provide guardianship paperwork if possible)
Other

What is your relationship to the aggrieved person?

Why is the aggrieved person unable to make the complaint?

Is the aggrieved person:

a person of Aboriginal descent (optional)
a person of Torres Strait Islander descent (optional)
a person with a disability (optional)

Who is the complaint about (the respondent)?

Who is the complaint about?

Organisation
Individual

Organisation name

Address (if known)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone

Name

First Last

Address (if known)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email (if known)

Phone (if known)

Do you want to add another respondent?

Yes
No

Who is the complaint about?

Organisation
Individual

Organisation name

Address (if known)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone

Name

Prefix First Last

Address (if known)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email (if known)

Phone (if known)

What are you complaining about?

When did the alleged event(s) happen?

Did the events happen in the ACT?

Yes
No

What happened?

Describe the events that you want to complain about with as much detail as you can. You need to say what happened, who did it and where it happened. If you wish to add additional respondents please list their details here.

Supporting documentation

If you have documents that can help us you can send them in and we will attach them to your complaint. Documents could include email correspondence, medical certificates, relevant photos etc. You can upload them below, or send them in an email to human.rights@act.gov.au

Drop files here or

Outcomes

What would you like to have happen to resolve your complaint?

Action Already Taken

Have you approached the person or organisation complained about?

Yes
No

Please provide details

Have you made a complaint to another organisation? (i.e. the Ombudsman or Australian Human Rights Commission)?

Yes
No

Please provide details, including the outcome of the complaint if known

Your details (the complainant)

Who is the complaint about (the respondent)?

What are you complaining about?

Outcomes

Action Already Taken

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