Positive Behaviour Support [Behaviour Support] Provider
Declaration Statement (NSW)
All providers (including sole practitioners) wishing to register as a provider of behaviour support
services must submit this Declaration Statement attesting that their relevant staff demonstrate
defined criteria regarding qualifications and experience to deliver behaviour support services to
NDIS participants in NSW. This declaration is in addition to the Third Party Verification (TPV)
requirements for this registration group.
All providers are required to comply with NSW legislation, policies and guidelines as outlined Module
4: Guide to Suitability.
Provider Information
Legal Entity Name
Organisation Trading Name
Leave blank if same as legal entity name
ABN
Address
Email address
Number of Behaviour
Support Practitioners
Ensure this is the same address as listed in your registration
application
Ensure this is the same address as listed in your registration
application
If sole practitioner state 1
Declaration
As an authorised representative of_____________________________________, I declare that:





I / We have read and understood the requirements as described in the ‘Guide to Suitability’;
I / We satisfy and will maintain the qualification and experience criteria for the registration
group as outlined in the TPV Verifier Confirmation attached to this Declaration Statement;
I / We satisfy the TPV requirements with specific emphasis on compliance with the NSW
Behaviour Support Policy;
I / We receive work practice support/supervision from a Behaviour Support Practitioner who
has a minimum of five years experience in the delivery of behaviour support. This support
and supervision includes:
o Data analysis
o Completion of Behaviour Assessments
o Completion of Behaviour Support Plans
o Development and delivery of training in Behaviour Support Plans
o Monitoring and Review of Behaviour Support Plans
o Evaluation of Behaviour Support Plan effectiveness; and
I / We will advise the NDIS immediately in the event of any changes to the above.
Signature ___________________
Date___________________
Positive Behaviour Support [Behaviour Support] Provider Declaration Statement
(NSW)
1
May 2017 – Version 3.0
Title _______________________
TPV Verifier Confirmation
Third Party Verification (TPV) verifiers are required to confirm that the provider (including sole
practitioners) meets the defined positive behaviour support criteria regarding qualifications and
experience to deliver behaviour support services to NDIS participants in NSW.
The TPV verifier must certify that the provider meets Element 1 OR Element 2; AND Elements 3, 4
and 5.
PART A
To complete this part of the form the Verifier must select the relevant qualification criteria that
apply to the provider or sole practitioner:
ELEMENT
REQUIREMENT
Criteria Met
EVIDENCE
1
Higher Education qualifications in
Psychology, Occupational Therapy,
Speech Pathology, Nursing, Social or
Health Sciences.

Qualification issued
from tertiary
institution.
2
Completed (within past 5 years) or
currently completing the Positive
Approach to Behaviour Support Core
Standard including Appraisal process
(FACS); or nationally recognised
competency CHCDIS006 – Develop and
promote positive person-centred
behaviour supports.

Certificate of
commencement,
progress or
completion issued by
FACS or by RTO as
relevant.
Positive Behaviour Support [Behaviour Support] Provider Declaration Statement
(NSW)
2
May 2017 – Version 3.0
PART B
To complete this part of the form the Verifier must confirm each requirement, name, date and
sign the bottom of this form.
ELEMENT
REQUIREMENT
3
Two years demonstrated experience in

the delivery of positive behaviour support
that includes:
o
o
o
o
o
o
4
Data analysis;
Completion of Behaviour
Assessments;
Development of Behaviour
Support Plans;
Development and delivery of
training in Behaviour Support
Plans;
Monitoring and Review of
Behaviour Support Plans;
Evaluation of Behaviour
Support Plan effectiveness.
Will receive, for the duration of their
registration, work practice
support/supervision from a Behaviour
Support Practitioner who has a
minimum of five years experience in the
delivery of behaviour support that
includes:
Data analysis;

o
Completion of Behaviour
Assessments;
Development of Behaviour
Support Plans;
Development and delivery
of training in Behaviour
Support Plans;
Monitoring and Review of
Behaviour Support Plans;
Evaluation of Behaviour
Support Plan effectiveness.

o
o
o
Third Party Verification with specific
emphasis on compliance with the NSW
Behaviour Support Policy.
Name of Verifier ___________________
EVIDENCE
Documented
employment history in
the role verified by
employer/s or by
other means (e.g.
record of contracts for
private
practitioners/sole
traders).
Documentation of
current agreement
with supervisor/work
practice support
practitioner (noting
duration of
agreement), and:
o
o
5
Criteria Met



Documented
employment history of
supervisor/work
practice support
practitioner verified by
employer or by other
means (e.g. record of
contracts/Statutory
Declaration for private
practitioners).


TPV certificate
Date___________________
TPV organisation ___________________
Positive Behaviour Support [Behaviour Support] Provider Declaration Statement
(NSW)
3
May 2017 – Version 3.0
Appendix – Positive Behaviour Support Criteria
Practitioners and organisations wishing to register as providers of behaviour support in NSW must submit a Declaration Statement using the approved form attesting that
they demonstrably meet the following criteria regarding qualifications and experience to deliver behaviour support services to NDIS participants in NSW. Providers must
attest that they meet Element 1 OR Element 2; AND Elements 3, 4 and 5.
ELEMENT
REQUIREMENT
EVIDENCE
1
Higher Education qualifications in Psychology, Occupational Therapy, Speech Pathology, Nursing, Social
or Health Sciences.
Qualification issued from tertiary institution.
2
Completed (within past 5 years) or currently completing the Positive Approach to Behaviour Support
Core Standard including Appraisal process (FACS); or nationally recognised competency CHCDIS006 Develop and promote positive person-centred behaviour supports.
Certificate of commencement, progress or
completion issued by FACS or by RTO as
relevant.
Two years demonstrated experience in the delivery of positive behaviour support that includes:
3
o
o
o
o
o
o
Documented employment history in the role
verified by employer/s or by other means (e.g.
record of contracts for private
practitioners/sole traders).
Data analysis;
Completion of Behaviour Assessments;
Development of Behaviour Support Plans;
Development and delivery of training in Behaviour Support Plans;
Monitoring and Review of Behaviour Support Plans;
Evaluation of their effectiveness
Will receive, for the duration of their registration, work practice support/supervision from a Behaviour
Support Practitioner who has a minimum of five years’ experience in the delivery of behaviour support
that includes:
4
5
o
o
o
o
o
o
Data analysis;
Completion of Behaviour Assessments;
Development of Behaviour Support Plans;
Development and delivery of training in Behaviour Support Plans;
Monitoring and Review of Behaviour Support Plans;
Evaluation of their effectiveness.
Documented employment history of
supervisor/work practice support practitioner
verified by employer or by other means (e.g.
record of contracts/Statutory Declaration for
private practitioners).
Third Party Verification with specific emphasis on compliance with the NSW Behaviour Support Policy.
Positive Behaviour Support [Behaviour Support] Provider Declaration Statement (NSW)
May 2017 – Version 3.0
Documentation of current agreement with
supervisor/work practice support practitioner
(noting duration of agreement), and:
4
TPV certificate.