Fillable Access Request Supporting Evidence Form (Department of Social Security and Welfare)

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Access Request Supporting Evidence Form (Department of Social Security and Welfare)

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Access Request – Supporting Evidence Form
The National Disability Insurance Agency (NDIA) will use the information in this form to determine if a person
meets the requirements to become a participant in the National Disability Insurance Scheme (NDIS).
NOTE: For children under 6 with a developmental delay, please use the Access Request – Supporting
Evidence Form for Children Under 6 with Developmental Delay.
Instructions for the person applying to
become an NDIS participant
Instructions for health or education
professionals
You do not need to complete this form if you can
provide recent existing information (letters,
assessments or other reports) from a health or
education professional which details:
• your impairment:
• how long it will last; and
• how it impacts on your daily life.
Section 1 can be completed by you, your parent,
representative or your health or educational
professional.
Sections 2 and 3 must be completed by a health or
education professional.
Enquiries: If you have questions about this form,
are having difficulty completing it, or would like more
information about the NDIS, please contact us:
Phone: 1800 800 110 TTY: 1800 555 677
Speak and Listen: 1800 555 727
Internet Relay: Visit http://relayservice.gov.au
and
ask for 1800 800 110
Email: NAT@ndis.gov.au
Please return the completed form to:
Mail: GPO Box 700, Canberra, ACT 2601
Email: NAT@ndis.gov.au
or take it to your local NDIA office.
Sections 2 and 3 must be completed by a health or
education professional.
You may provide the person applying to the NDIS
with copies of letters, assessments or other reports
in lieu of completing this form.
If you have any questions about this form, please
contact the NDIA on 1800 800 110 or go to
ndis.gov.au
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Supporting Evidence Form 1.1 – 8 April 2020
Section 1: Details of the person applying to become a participant in the NDIS
This part of the form can be completed by you, a parent, representative or professional
Full name
Date of birth
Name of parent/ guardian/ carer/
representative
Phone
NDIS number (if known)
Section 2: Details of the person’s impairment/s
This part of the form must be completed by a treating doctor or specialist
1. Details of the health professional completing Section 2
Full name of health professional
Professional qualifications
Address
Phone
Email
Signature
Date
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Personal-In-Confidence when complete
Supporting Evidence Form 1.1 – 8 April 2020
2. Details of the person’s impairment/s
2.1 What is the person’s primary
impairment (i.e., the impairment
with the most impact on daily life)?
2.2 How long has the person had
this impairment?
2.3 Is the impairment likely to be
lifelong?
Note: an impairment may be
considered likely to be lifelong even
if the impact on the functional
capacity fluctuates or varies in
intensity over time.
2.4 Please provide a brief
description of any relevant
treatment undertaken (current
and/or past)
2.5 Does the person have another
impairment that has a significant
impact? If yes, please list.
2.6 How long has the person had
this impairment?
2.7 Is the impairment likely to be
lifelong?
2.8 Please provide a brief of any
relevant treatment undertaken
(current and/or past)
2.9 Does the person have any
other impairments? If yes, please
list
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Personal-In-Confidence when complete
Supporting Evidence Form 1.1 – 8 April 2020
2. Are there early intervention supports that are likely to benefit the person by reducing their future
needs for supports? If yes, please tick and write details. If no, proceed to question 4.
The provision of early supports will:
Please tick
☐ Alleviate the impact on functional capacity
☐ Prevent deterioration of functional capacity
☐ Improve functional capacity
☐ Strengthen the sustainability of available or
existing supports
Details of recommended early intervention
supports:
3. Have any assessments been undertaken of the person’s impairment(s)?
If yes, please write details and tick if assessment is attached to form. If no, proceed to Section 3.
Please record assessment type, the date the assessment was undertaken and the assessment
score or rating. Please tick
Assessment Type
Date
completed
Score or
rating
Assessment attached to
this form?
Care and Need Scale (CANS)
☐ Yes ☐ No
Gross Motor Functional Classification Scale
(GMFCS)
☐ Yes ☐ No
Hearing Acuity Score
☐ Yes ☐ No
Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5)
☐ Yes ☐ No
Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-4)
☐ Yes ☐ No
Visual Acuity Rating
☐ Yes ☐ No
Communication Function Classification System
(CFCS)
☐ Yes ☐ No
Vineland Adaptive behaviour Scale (Vineland-II)
☐ Yes ☐ No
Modified Rankin Scale (mRS)
☐ Yes ☐ No
Manual Ability Classification Scale (MACS)
☐ Yes ☐ No
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Personal-In-Confidence when complete
Supporting Evidence Form 1.1 – 8 April 2020
Assessment Type
Date
completed
Score or
rating
Assessment
attached to this
form?
American Spinal Injury Association Impairment
Scale (ASIA/AIS)
☐ Yes ☐ No
Disease Steps
☐ Yes ☐ No
Expanded Disability Status Scale (EDSS)
☐ Yes ☐ No
Other (please specify):
☐ Yes ☐ No
Section 3: Details of the functional impact of the impairment/s
This part of the form must be completed by a health or education professional
You can provide an existing report instead of completing this Section, however it is
important that the information you provide matches the information required by this Section.
FUNCTIONAL IMPACT
1. Mobility
Moving around the home, getting in and out of bed or a chair, mobilising in the community including
using public transport or a motor vehicle.
*Assistance required does not include commonly used items such as glasses, walking sticks, non-
slip bath mats, bathroom grab rails and hand rails installed at stairs.
Does the person require assistance to
be mobile because of their
impairment/s?
☐ No, does not need assistance
☐ Yes, needs special equipment
☐ Yes, needs assistive technology
☐ Yes, needs home modifications
☐
Yes, needs assistance from other persons
(including physical assistance, guidance, supervision
or prompting)
If yes, please describe the type of assistance required:
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Personal-In-Confidence when complete
Supporting Evidence Form 1.1 – 8 April 2020
2. Communication
Being understood in spoken, written or sign language and ability to understand language and
express needs and wants by gesture, speech or context appropriate for age.
Does the person require assistance to
communicate because of their
impairment/s?
☐ No, does not need assistance
☐ Yes, needs special equipment
☐ Yes, needs assistive technology
☐ Yes, needs home modifications
☐ Yes, needs assistance from other persons
(including physical assistance, guidance, supervision
or prompting)
If yes, please describe the type of assistance required:
3. Social interaction
Making and keeping friends and relationships, behaving within limits accepted by others, coping
with feelings and emotions.
Does the person require assistance to
interact socially because of their
impairment/s?
☐ No, does not need assistance
☐ Yes, needs special equipment
☐ Yes, needs assistive technology
☐ Yes, needs assistance from other persons:
(including physical assistance, guidance, supervision
or prompting)
If yes, please describe the type of social interaction assistance required:
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Personal-In-Confidence when complete
Supporting Evidence Form 1.1 – 8 April 2020
4. Learning
Understanding and remembering information, learning new things, practicing and using new skills
Does the person require assistance to
learn effectively because of their
impairment/s?
☐ No, does not need assistance
☐ Yes, needs special equipment
☐ Yes, needs assistive technology
☐
Yes, needs assistance from other persons:
(including physical assistance, guidance, supervision
or prompting)
If yes, please describe the type of assistance required:
5. Self-Care
Showering/ bathing, dressing, eating, toileting, caring for own health.
Note: Assistance required does not include commonly used items such as non-slip bath mats,
bathroom grab rails and hand rails installed at stairs.
Does the person require assistance
☐ Yes, need special equipment
with self-care because of their
impairment/s?
☐ Yes, needs assistive technology
☐ No, does not need assistance
☐ Yes, needs home modification
☐
Yes, needs assistance from other persons in the areas
of:
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Personal-In-Confidence when complete
Supporting Evidence Form 1.1 – 8 April 2020
☐ showering/bathing
☐ eating/drinking
☐ overnight care (e.g. turning)
☐ toileting
☐
dressing
If yes, please describe the type of assistance required:
6. Self-Management
Doing daily jobs, making decisions and handling problems and money (not applicable for children
under 8 years of age)
Does the person require assistance
with self-management because of
their disability?
☐ No, does not need assistance
☐ Yes, needs special equipment
☐ Yes, needs assistive technology
☐ Yes, needs assistance from other persons:
(physical assistance, guidance, supervision or prompting)
If yes, please describe the type of assistance required:
8 of 8
Personal-In-Confidence when complete
Supporting Evidence Form 1.1 – 8 April 2020
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Access Request Supporting Evidence Form (Department of Social Security and Welfare)

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Completed 20 November 2020

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