Participant Risk Assessment Form
Participant Information, Risk Identification, Control Measures, and Supervisor Review.
Participant Information & Assessment Details
| Full Name: | |
| Date of Birth: | |
| NDIS Number: | |
| Phone Number: | |
| Mobile Number: | |
| Email Address: | |
| Address: |
Person completing the assessment
| Assessor Name: | |
| Position Title: | |
| Date of Assessment: | |
| Reported to (Manager/Supervisor): | |
| Signature: |
Risk Assessment Guidance
Risks are to be determined based on information gathered as part of the referral, intake assessment or support planning process.
Some examples of risks may include:
- The participant is known to be potentially aggressive, violent or disturbed.
- There is evidence that the participant or family member/carer at the premises may be under the influence of alcohol or drugs.
- The participant may be at risk of self-harm.
Risk Assessment Matrix
| Risk Description | Who might be affected/impacted | Risk rate | Control Measures |
|---|---|---|---|
| Describe the risk and possible consequences/impact | Risk to the participant, staff or other clients. | Specify the risk rate based on the Risk Assessment Matrix | Describe the control measure to minimise the risk |
| Risk assessment notes: |
Supervisor/Manager
| Full Name: | |
| Signature: | |
| Date: |
