Strivesocial: Participant Risk Assessment Form
PARTICIPANT DETAILS
Given name/s
Family name
Preferred name
Date of Birth
Address
Phone number:
Email address
Preferred contact method
Participant Requirements / Preferences
Preferred communication mode and language
Cultural requirements
Religious/belief based requirements
Interests
Physical requirements
Known Medical Conditions or Allergies
Specify
Effect
Treatment
Emergency Contacts
Name/s:
Phone:
Email address
CARER / GUARDIAN DETAILS
Family name
Given name/s
Email address
Phone number
Postal address
In-person contact
Specify frequency for participants who live alone:
Persons involved in the risk assessment
Was the participant involved in the assessment?
Yes
Declined
Reason:
Unable
Reason:
Staff Involved
Others Involved
Daily Personal Activities – for participants living alone
Sole Support Worker
Yes
Reason:
Participant preference
Other:
(If yes, a Monitoring and Supervision Plan is required)
Information Sharing and Privacy
Privacy Policy Explained
Yes
Comments / feedback:
Sharing information
Consent to share information documented
Other Provider/s
List:
Comments
Risk Identification
Risk category
Risk factors
Tick all applicable risks
Daily Personal Activities Support – for participants living alone
Personal contact
No regular face-to-face contact with other NDIS providers
☐
Limited or irregular face-to-face contact with relatives, friends or other people
☐
Physical Mobility
Relies on other people to be physically mobile or to facilitate their physical mobility
☐
Uses equipment to enable them to be physically mobile or to facilitate their physical mobility.
☐
Communication
Without the assistance of another person the participant has limited or no ability to communicate.
☐
The participant uses equipment to enable or facilitate communication with others, including to enable or facilitate the use of a phone or other device.
☐
Note: If supports will be delivered by a sole support worker, and any of the above risks apply, a Monitoring and Supervision Plan must be created.
To what degree does the participant rely on our services? Explain below
How would the participants’ health and safety be impacted if their service was disrupted?
Medical conditions and interventions
☐ Fractures, cuts
☐ Bruising, abrasions
☐ Seizures
☐ Respiratory conditions
☐ Allergies
☐ Skin conditions
☐ Endocrine conditions
☐ Diabetes
☐
☐ Sleep disorders
☐ Constipation
☐ Incontinence
☐ Dementia
☐
☐ Obesity
☐ Teeth and gum conditions
☐ Night timechecking required
☐ Missed appointments
☐
☐ Medication
☐ Not taking medication
☐ Decline to participate in medical examinations or procedures
☐ Decline to follow medical advice
☐ Infectious disease
☐ Other (specify)
Personal care
☐ Feeding
☐ Toileting
☐ Showering/ bathing
☐ Dental hygiene
☐ Shaving
☐ Grooming
☐ Other (specify)
Eating and drinking
☐ Swallowing difficulty
☐ Choking on food
☐ Enteral feeds – plus oral intake
☐ Enteral feeds - nil by mouth
☐ Food allergies
☐ Specialised diet
☐ Texture modified diet
☐ Thickened fluids
☐ Overnight feeds required
☐ Food refusal
☐ Dehydration
☐ Posture and positioning
☐ Alertness
☐ Modified utensils or equipment
☐ Behaviour related to eating or drinking
☐ Pica (eating non-food items)
☐ Environment
☐ Other (specify)
Accidental movement
☐ Startle reflex
☐ Panic behaviour
☐ Grabbing, holding, leaning
☐ Sudden body movements
☐ Falling, tripping
☐ Bumping, running
☐ Other (specify)
Manual handling
☐ Transfers
☐
☐ Mobility
☐
☐ Vehicle access
☐ Moving in bed
☐ Personal care tasks
☐
☐ Other (specify)
Environmental risks
☐ Electrocution
☐ Fire lighting, flammables
☐ Smoking
☐ Sharps/knives
☐ Poisons
☐ Water hazard/ bathing
☐ Sun exposure
☐ Absconding/ wandering
☐ Traffic (roads and rail)
☐ Travel (private/public transport)
☐ Other (specify)
Mental health and wellbeing
☐ Suicide risk
☐ Self-harm/ self-injury
☐ Mental health diagnosis
☐ Self-neglect
☐ Hoarding
☐ Other (specify)
Financial risks
☐ Low income
☐ Limited understanding of money
☐ Challenges developing and sticking to a budget
☐ Vulnerable to financial exploitation
☐ Losing wallet/ purse/ bag
☐ Debt
☐ Gambling
☐ Other (specify)
Social risks
☐ Exploitation
☐ Unsafe sex
☐ Physical abuse/ threats
☐ Verbal abuse/ threats
☐ Harassment/ stalking
☐ Emotional abuse
☐ Sexual abuse/ threats
☐ Neglect
☐ Use of projectiles or weapons
☐ Property damage
☐ Harm to animals
☐ Domestic violence
☐ Criminal/ illegal behaviour
☐ Social isolation
☐ Lack of informal supports
☐ Strangers
☐ Anti-social peers
☐ Other housemates
☐ Other visitors to home
☐
☐ Family and carers
☐ Discrimination
☐ Homelessness
☐ Leaving care
☐
☐ Other (specify)
Substance use
☐ Drugs
☐ Medication misuse
☐ Alcohol
☐
☐ Smoking
☐ Other (specify)
Other
Other identified risks:
Monitoring and supervision plan
Is Personal Support (Assistance with Daily Personal Activities) being provided by a sole Worker?
☐ Yes
☐ No
If so, set out the frequency at which Strivesocial will undertake in-person supervision of the Worker. It could be weekly, monthly, bi-monthly, quarterly or six-monthly dependent on the individual circumstances.
If so, set out the frequency that will be used to engage with providers who may be involved in providing Other Support Services to the Client in their home or in supporting the Client to access community based activities.
Develop a risk management plan for all identified risks above.
RISK MANAGEMENT PLAN
Type of Risk
Likely Effect Level
Risk Treatment
Person Responsible
Review Date
Participant
Others
Participant/Representative Name: ___________________________________________
Participant/Representative Signature: __________________________ Date: _____________
Manager/Supervisor Name: ________________________________________________
Manager/ Supervisor Signature: _______________________ Date: _____________
Risk Assessment Review
Date
Reason for Review
☐ Scheduled Review
☐ Feedback
☐ Change in Participant Needs/ Circumstances
Outcome of Review and Actions to be Taken
Details:
☐ New Risk Assessment completed
☐ No Changes Required, Next Scheduled Review Date:
Review Completed By
Signature