DOCUMENT 5
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). 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 a participant in the NDIS
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.
How to complete this form:
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 educational professional.
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: nationalaccessteam@ndis.gov.au
Returning this form:
Please return the completed form to:
Mail: GPO Box 700, Canberra, ACT 2601 Email: NationalAccessTeam@ndis.gov.au
Or take it to your local NDIA office.
Instructions for the health or educational Professional completing this form
Sections 2 and 3 of this form 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
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 | Annabel Smith |
|---|---|
| Date of Birth | 52 years old |
| Name of parent/ guardian/ carer/ representative | redacted |
| Phone | redacted |
| NDIS number (if known) | redacted |
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 | Jane Brown |
|---|---|
| Professional Qualification | Local GP |
| Address | redacted |
| Phone | redacted |
redacted |
|
| Signature | J.Brown |
| Date |
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)? | Fibromyalgia |
| 2.2 How long has the person had this impairment? | 10+ Years |
| 2.3 Is the impairment likely to be lifelong? NB: an impairment may be considered likely to be lifelong even if the impact on the functional capacity fluctuates or varies in intensity over time. |
Yes |
| 2.4. Please provide a brief description of any relevant treatment undertaken (current and/or past) | Pain Medication |
| 2.5. Does the person have another impairment that has a significant impact? If yes, please list | Chronic Fatigue Syndrome |
| 2.6. How long has the person had this impairment? | 10+ Years |
| 2.7. Is the impairment likely to be lifelong? | Yes |
| 2.8. Please provide a brief of any relevant treatment undertaken (current and/or past) | No Treatment Available |
| 2.9. Does the person have any other impairments? If yes, please list | Not Applicable |
3. Are there early intervention supports that are likely to benefit the person by reducing their future needs for supports?
The provision of early supports will:
- 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:
OT Home assessment required Physiotherpay
4. Have any assessments been undertaken of the person’s impairment(s)?
Please record assessment type, the date the assessment was undertaken and the assessment score or rating
| Assessment Type* | Date Completed | Score or Rating | Assessment attached to this form? |
|---|---|---|---|
| Care and Need Scale (CANS) | [x] Yes [ ] No | ||
| Gross Motor Functional Classification Scale (GMFCS) | [x] Yes [ ] No | ||
| Hearing Acuity Score | [ ] Yes [x] No | ||
| Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) | [x] Yes [ ] No | ||
| Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-4) | [ ] Yes [x] No | ||
| Visual Acuity Rating | [ ] Yes [x] No | ||
| Communication Function Classification System (CFCS) | [ ] Yes [x] No | ||
| Vineland Adaptive behaviour Scale (Vineland-ll) | [ ] Yes [x] No | ||
| Modified Rankin Scale (mRS) | [ ] Yes [x] No | ||
| Manual Ability Classification Scale (MACS) | [ ] Yes [x] No | ||
| American Spinal Injury Association Impairment Scale (ASIA/AIS) | [ ] Yes [x] No | ||
| Disease Steps | [ ] Yes [x] No | ||
| Expanded Disability Status Scale (EDSS) | [ ] Yes [x] No | ||
| Other ……………………………………………………………… | [ ] Yes [x] 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.
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? | [ ] Yes, needs special equipment [ ] Yes, needs assistive technology [ ] Yes, needs home modifications [x] Yes, needs assistance from other persons (including physical assistance, guidance, supervision or prompting) [ ] No, does not need assistance |
|---|
If yes, please describe the type of assistance required:
Annabel uses a walking stick indoors and outdoors for short distances. In shopping centres or for longer distances she required a 4WW. She is able to walk approximately 150m before requiring breaks. She is struggles to get up and down stairs.
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? | [ ] 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) [x] No, does not need assistance |
|---|
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? | [ ] Yes, needs special equipment [ ] Yes, needs assistive technology [x] Yes, needs assistance from other persons: (including physical assistance, guidance, supervision or prompting) [ ] No, does not need assistance |
|---|
If yes, please describe the type of social interaction assistance required:
Annabel would benefit from transport to and from social events
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? | [ ] Yes, needs special equipment [ ] Yes, needs assistive technology [ ] Yes, needs assistance from other persons: (including physical assistance, guidance, supervision or prompting) [x] No, does not need assistance |
|---|
If yes, please describe the type of assistance required:
5. Self-Care
Showering/ bathing, dressing, eating, toileting, caring for own health.
- 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 with self-care because of their impairment/s? | [x] Yes, need special equipment [x] Yes, needs assistive technology [x] Yes, needs home modification [x] Yes, needs assistance from other persons in the areas of: [x] showering/bathing [x] toileting [x] eating/drinking [x] dressing [ ] overnight care (e.g. turning) [ ] No, does not need assistance |
|---|
If yes, please describe the type of assistance required:
Annabel struggles to perform self-care tasks independently. She would benefit from an OT assessment. She is not able to stand up for a long time to prepare meals and therefore does not have a nutritious diet.
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? | [ ] Yes, needs special equipment [ ] Yes, needs assistive technology [x] Yes, needs assistance from other persons: (physical assistance, guidance, supervision or prompting) [ ] No, does not need assistance |
|---|
If yes, please describe the type of assistance required:
Annabel needs assistance to complete house work. She is unable to change the sheets on her bed and she cannot hang her washing on the line.