Forms
Schedule 1 Forms
FORM 1
NOMINATION OF RESTRICTIVE PRACTICES NOMINEE
Regulation 5
Full name of person making the nomination:
Date of birth of person making the nomination:
Residential address of person making the nomination:
NOMINATION
I nominate [insert name of nominee] of [insert residential address of nominee] to be my restrictive practices nominee under section 5 of the Aged Care Restrictive Practices Substitute Decision-maker Act 2024.
In signing this nomination form, I confirm that:
- I am 18 years of age or older; and
- I have decision-making capacity at the time of making this nomination to make this nomination; and
- I understand the nature and effect of this nomination.
My preferences and values regarding the use of restrictive practices are: [insert preferences and values or "Nil"].
Signed: [signature of person making the nomination]
Date:
DESCRIPTION OF ASSISTANCE PROVIDED (if any)
Assisted by:
Full name of person assisting:
Address of person assisting:
I confirm that I provided the following assistance to the person making this nomination: [insert description. For example, translation assistance, assistance with writing or reading]
Signed: [signature of person who assisted the person making the nomination]
Date:
CERTIFICATE OF WITNESS
Witnessed by:
Full name of witness:
Address of witness:
I certify that:
- at the time of signing this document, the person making this nomination:
- appears to me to have decision-making capacity; and
- appears to me to understand the nature and consequences of making the nomination;
- appears to me to freely and voluntarily sign this document;
- I am not the person named in this nomination as the restrictive practices nominee;
- I am not a relative of the person making this nomination; and
- I am not an employee or agent of an approved provider that provides aged care to the person making this nomination.
Signed: [signature of witness who must be an authorised affidavit taker]
Capacity in which authorised affidavit taker has authority to witness this nomination:
Date:
FORM 2
REVOCATION OF NOMINATION OF RESTRICTIVE PRACTICES NOMINEE
Regulation 6
Full name of person revoking the nomination:
Date of birth of person revoking the nomination:
Residential address of person revoking the nomination:
REVOCATION
I revoke the nomination of [insert name of restrictive practices nominee] of [insert residential address of nominee] under section 6 of the Aged Care Restrictive Practices Substitute Decision-maker Act 2024.
In signing this revocation form, I certify that:
- I have decision-making capacity at the time of making this revocation to revoke the nomination; and
- I understand the nature and effect of this revocation.
Signed: [signature of person revoking the nomination]
Date:
DESCRIPTION OF ASSISTANCE PROVIDED (if any)
Assisted by:
Name of person assisting:
Address of person assisting:
I confirm that I provided the following assistance to the person making the revocation: [insert description. For example, translation assistance, assistance with writing or reading]
Signed: [signature of person who assisted the person making the revocation]
Date:
CERTIFICATE OF WITNESS
Witnessed by:
Name of witness:
Address of witness:
I certify that:
- at the time of signing this document, the person revoking the nomination:
- appears to me to have decision-making capacity; and
- appears to me to understand the nature and consequences of making the revocation;
- appears to me to freely and voluntarily sign this document;
- I am not the person named in this revocation as the restrictive practices nominee;
- I am not a relative of the person making this revocation; and
- I am not an employee or agent of an approved provider that provides aged care to the person making this revocation.
Signed: [signature of witness who must be an authorised affidavit taker]
Capacity in which authorised affidavit taker has authority to witness this nomination:
Date:
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