Notification of Approval or Consent to
the Use of Restrictive Practices
Approved Restrictive Practice Reporting
Form 6-4
When this form is to be used
 By a Relevant Service Provider, after receiving any approval for the use of restrictive practices, at a Service
Outlet (Disability Services Act 2006, Section 195).


After each subsequent review and approval given for the use of restrictive practices.
To record appointment of, or all changes to, guardianship.
How to complete this form
Under the Disability Services Act 2006 a service outlet means a place at which disability services are provided.
Limited restrictive practice approval means a restrictive practice approval other than—


a containment or seclusion approval; or

a short term approval given by the public guardian under the Guardianship and Administration Act 2000, chapter
5B, part 4.
A relevant service provider is required to complete and return this form to the Department of Communities, Child
Safety and Disability Services within:

14 days if the limited restrictive practice approval is a short-term approval and given by the Department of
Communities, Child Safety and Disability Services or

21 days after consent to use of a restrictive practice is given by either a guardian for a restrictive practice (general
or respite) matter or an informal decision maker.

This form must be completed with contact details and a signed declaration (Part D).

Print clearly, using BLOCK letters and indicate with a tick () where required.

The ‘Provider Outlet Reference’ number must be completed.
Your privacy
The information on this form is being collected so Disability Services clinical teams can provide oversight and support in relation to the
development, approval and use of positive behaviour support plans and restrictive practices. The collection is authorised by the
Disability Services Act 2006. Information may be disclosed to statutory bodies and non-government service providers involved in this
process, as part of that oversight and support functions. All personal information will be handled in accordance with the Information
Privacy Act 2009.
Part A – Details of the Adult
Last Name
Gender
First Name
Male
/
Date of Birth
-
BIS ID
Female
Address
/
NDIS ID
Suburb
Postcode
Part B – Approval/Consent details
Who approved or gave consent to the use of the restrictive practice(s)?
Short Term Approval
Chemical Restraint (Fixed Dose) only
Positive Behaviour Support Plan
[No plan required – go to Part C]
Dated:
Delegate of the Chief Executive
/
/
Respite/Community Access Plan
QCAT
Public Guardian
Dated:
/
/
Guardian for RP (General)
Guardian for RP (Respite)
Relevant Decision Maker
Relevant Decision Maker
Period of Approval / Consent
Short Term Approval
/
/
to
/
/
(period of approval)
Positive Behaviour Support Plan
/
/
to
/
/
(period of consent)
RPAppNotif: Approved Restrictive Practice Reporting
Issue 01
Respite / Community Access Plan
/
/
to
/
/
(period of consent)
Page 1 of 2
Date: 31/07/2017
Appointment of a Guardian for Restrictive Practices (general or respite)
Approved Restrictive Practice Reporting
Guardian for RP (General)
Guardian Name:
Guardian for RP (Respite)
Appointed from:
/
/
to
/
/
What Restrictive Practices have been approved/consented to?
Containment
Seclusion
Chemical Restraint
Restricted Access
Item or Location:
Mechanical Restraint
Device:
Physical Restraint
Method:
Part C – Relevant Service Provider – Outlet details
OUTLET Name
OUTLET Reference
Address
Suburb
Postcode
Part D – Declaration
,
(Registered name of association or company)
trading as
of
(Street address)
,
.
Telephone number: (
)
.
Facsimile number: (
)
.
@
,
Email address:
does hereby submit a notification under Section 195(1) of the Disability Services Act 2006 and declare that
all information supplied herein is true at the time of this notification.
Dated this
day of
Name:
Position:
20
.
.
.
Signature: …………………………………………..………...
Sign off should be by the person who has the appropriate authority to sign on behalf of the company or
association.
Once completed, send form to:
Email: Director of Clinical Practice in your local region
Please check the Contact information section of the Positive Behaviour Support website for the latest
details.
RPAppNotif: Approved Restrictive Practice Reporting
Issue 01
Page 2 of 2
Date: 31/07/2017