Applicant

Adult Safeguarding Unit - Internal Review Application Form

Under Section 38 of the Ageing and Adult Safeguarding Act 1995, if you are aggrieved by a relevant decision of the Director of the Office for Ageing Well or Adult Safeguarding Unit under Part 4 of the Ageing and Adult Safeguarding Act 1995 (a reviewable decision), you may use this form to request an internal review of the decision.

You must submit the application form within 30 calendar days of being provided with notice of the decision (unless the DHS Chief Executive or their delegate approves a longer period).

The decision notice and/or related correspondence should be attached to this application form where it is available.

If your concern does not relate to a reviewable decision, but you would like it formally considered, please submit a complaint in writing by emailing ofawfeedback@sa.gov.au.

Required fields are marked with an asterisk *

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Applicant details

Given name *

Family Name *

Postal address *

Suburb *

Postcode *

Phone

Applicant type

I am the relevant adult (a person aged 18 or older who may be vulnerable to abuse and is the subject of a decision made by the Unit)Other

Please describe

Adult Safeguarding Unit matter / reference number (if known)

Preferred contact method *

PostPhoneEmailThrough representative/support person

Name of representative/support person

Contact details for representative/support person

Relevant adult details

About the Relevant Adult

Please describe

Relevant adult given name

Relevant adult family name

Phone

Date of birth or approximate age *

Is the relevant adult aware of this application? *

YesNoUnsure

Please explain if it is safe and appropriate to contact the Relevant Adult *

Decision to be reviewed

Decision you would like reviewed

I am not satisfied with a decision made by the Director or the Adult Safeguarding Unit *

Date you received notification of this decision

Name/position of decision maker (if known)

Attach a copy of the decision notice or related correspondence if available

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Choose the option that most accurately reflects the decision you wish to have reviewed pursuant to section 38 of the Ageing and Safeguarding Act 1995 *

The decision to undertake a safeguarding response (section 27)The decision to monitor a safeguarding response (section 27)The decision to refer a matter to a law enforcement agency, regulatory agency or complaints body (section 24)The decision to undertake an investigation to make or support an application to the South Australian Civil and Administrative Tribunal (section 25)The decision to provide information, education or advice (section 23)The decision to take no further action following an assessment (section 23)The decision to act without first obtaining the consent of the relevant adult (section 28)Other decision

Please describe

Time period

An application for an internal review must be made within 30 calendar days of the applicant being given notice of the decision unless the DHS Chief Executive or their delegate allow a longer period.

My application is within the 30-day time limitMy application is outside the 30-day time limit

Describe why the review period should be extended

Additional information

Please describe how you are affected (aggrieved) by the decision and the reasons you want the decision reviewed *300 word limit

Please describe the outcome you are seeking (whether you are asking for the decision to be varied or reversed, and what action you would like taken and why)300 word limit

Supporting documents

Supporting documents checklist (where available and applicable)

Decision noticeRelevant correspondenceAuthority to act/consent, if applying on behalf of someone elseEvidence supporting extension of timeOther documents

Please describe

Upload supporting documents

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Please provide any additional information (relevant information or additional comments you think may assist the review).300 word limit

Declaration

I declare that, to the best of my knowledge, the information provided in this application and supporting documentation is true and correct. *

Date *