NDIA Accountability Project

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Early childhood – Provider report form

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Early childhood – Provider report form

Providers will use this form to record how the early childhood supports or therapy supports they have provided have assisted the child and their family or carer (family) to:

  • work towards their goals
  • maximise their independence
  • join in everyday activities and routines at home
  • participate in community and educational settings.

Include information on:

  • the child and family’s progress towards their goals
  • the child’s functional capacity, independence, and participation in daily activities
  • the outcomes of the supports the family and child have received
  • future goals and recommendations.

Who should use this form

A provider delivering early childhood supports for a participant younger than 7 or therapy supports for a participant who is 7 or 8 years old.

How to use this form

There are 9 parts to this form. Part D and Part E can be completed where applicable.

It is strongly recommended that providers complete this form at least annually in collaboration with the child’s family.

’This form is a fillable PDF. The ‘fill and sign’ functionality within Adobe PDF secures the document once it has been signed. It can no longer be edited once it has been signed and saved. Only add your signature to the form when it has been finalised.

How to return this form

Complete and provide a copy of the form to the child’s family to share with their My NDIS Contact, who is their partner or planner. With the family’s permission, providers can also send a copy of the report directly to the participant’s My NDIS Contact.

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Part A: Child, family and provider details

Child and family’s details
Child’s full name
NDIS number
Date of birth (DD/MM/YYYY)
Parent or carer name

Provider details
Professional’s full name
Professional qualification(s)
Professional registration number (if applicable)
Are you the key worker/lead practitioner for this child? (Yes/No/Not Applicable)
Business name
Business address
Phone number
Email
Date services commenced (DD/MM/YYYY)
Report date (DD/MM/YYYY)

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Other professionals contributing to this form (if applicable)

Full name (Include your organisation’s business name if applicable) Qualification

Part B: Summary of supports

In this section, please summarise:

  • the setting, delivery mode, frequency, and duration of supports provided
  • the important people in the child’s life involved in the delivery of supports, education and/or care.

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Part C: Goals and outcomes

Document the early intervention or therapy goals you developed with the child’s family. Include which NDIS goals they relate to. You can enter more than one goal into the same table, where progress and outcomes are similar across goals. Alternatively, you may separate goals across the tables to allow for progress and outcomes to be reported separately.

Complete the goals and outcomes tables as required. If you need to report on more goals and outcomes, please copy and paste the table.

1.1 Goals and outcomes table

Child and family’s early intervention or therapy goal(s): Record the early intervention or therapy goal(s) you have developed with the family.

NDIS goal(s): Record the NDIS goal(s) which relate to the above early intervention or therapy goal(s).

Progress and outcomes: Comment on the child’s function and participation at the start of the reporting period, and the child and family’s progress towards goals. Comment on independence, participation, and capacity building. Name the outcome measurement tool(s) or other forms of evidence, including baseline and review scores/descriptors. You can also list and attach additional evidence in Part D of this form.

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1.2 Goals and outcomes table

Child and family’s early intervention or therapy goal(s): Record the early intervention or therapy goal(s) you have developed with the family.

NDIS goal(s): Record the NDIS goal(s) which relate to the above early intervention or therapy goal(s).

Progress and outcomes: Comment on the child’s function and participation at the start of the reporting period, and the child and family’s progress towards goals. Comment on independence, participation, and capacity building. Name the outcome measurement tool(s) or other forms of evidence, including baseline and review scores/descriptors. You can also list and attach additional evidence in Part D of this form.

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1.3 Goals and outcomes table

Child and family’s early intervention or therapy goal(s): Record the early intervention or therapy goal(s) you have developed with the family.

NDIS goal(s): Record the NDIS goal(s) which relate to the above early intervention or therapy goal(s).

Progress and outcomes: Comment on the child’s function and participation at the start of the reporting period, and the child and family’s progress towards goals. Comment on independence, participation and capacity building. Name the outcome measurement tool(s) or other forms of evidence, including baseline and review scores/descriptors. You can also list and attach additional evidence in Part D of this form.

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1.4 Goals and outcomes table

Child and family’s early intervention or therapy goal(s): Record the early intervention or therapy goal(s) you have developed with the family.

NDIS goal(s): Record the NDIS goal(s) which relate to the above early intervention or therapy goal(s).

Progress and outcomes: Comment on the child’s function and participation at the start of the reporting period, and the child and family’s progress towards goals. Comment on independence, participation, and capacity building. Name the outcome measurement tool(s) or other forms of evidence, including baseline and review scores/descriptors. You can also list and attach additional evidence in Part D of this form.

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Part D: Additional evidence (if applicable)

Name and attach any relevant assessments, reports, outcome measures or therapy plans.

Name of attachment Date (DD/MM/YYYY)

Part E: Additional information (if applicable)

Comment on any changes in the child or family’s circumstances throughout the plan period. Include, for example, new priorities or barriers identified which impacted on the child and family’s outcomes. Comment on how you supported the family, worked with other mainstream service systems and any successes to date.

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Part F: Future child and family early intervention or therapy goals

Record future child and family early intervention or therapy goals.

Part G: Provider recommendations

Describe recommended future supports the child and family are likely to benefit from and why. This should include community and mainstream supports and NDIS funded supports (if applicable).

Include justification for any recommended NDIS funded supports, including how you have considered the NDIS funding criteria and expected functional, independence and social outcomes.

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Part H: Report completed

I confirm that the information provided in this form is complete and correct.

I understand that:

  • giving false or misleading information is a serious offence
  • this information is protected by law and can only be given to someone else where Commonwealth law allows, or requires it, or where I give permission.
Professional’s full name
Signature SIGN
Date of signature (DD/MM/YYYY)

Part I: Important actions before submitting this form

  • This form has been discussed with the child’s family.

  • The child’s family have received a copy of this form.

Privacy and your personal information

Collection of your personal information

The National Disability Insurance Agency (NDIA) would like some personal information from you to assist in supporting the NDIS participant and their family or carers under the NDIS.

Any personal information you provide to the National Disability Insurance Agency (NDIA) in this form is safe under the National Disability Insurance Scheme Act 2013 and the Privacy Act 1988. You can also ask to see what personal information (if any) we hold about you at any time and can seek correction if the information is wrong.

Personal information use and disclosure

The NDIA will use the personal information provided in this form to support the NDIS participant’s involvement in the NDIS.

The NDIA will NOT use this personal information for any other purpose or disclose your personal information to any other organisations or individuals (including any overseas recipients), unless authorised by law or you provide your consent for us to do so.

The NDIA’s privacy policy describes

  • how we use your personal information.
  • why some personal information may be given to other organisations from time to time.

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  • how you can access the personal information we have about you on our system.
  • how you can complain about a privacy breach, and how the NDIA deals with the complaint.
  • how you can get your personal information corrected if it is wrong.

You can find out more about how we collect, use and disclose your personal and sensitive information on the NDIS website (ndis.gov.au). Select ‘About’, then ‘Policies’, ‘Freedom of Information’ and ‘Privacy’ from the menu on the right.

Personal information storage

The NDIA uses an Australian Government computer system to store personal information. System users, other than NDIA staff, may at times be able to see your name when they perform program duties, however they can’t record, use or disclose information, and they will not know if you become an NDIS participant. State or territory government officials may also have personal information access as part of the agreement between governments to assist the states and territories in their NDIS evaluation.