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'NOTIFICATION OF CHANGES TO KEY PERSONNEL' FORM

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					        APPROVED PROVIDERS under the AGED CARE ACT 1997
 ‘NOTIFICATION OF CHANGES TO KEY PERSONNEL’ FORM

This form is to be used to notify the Department of Health and Ageing of a change to your Key
Personnel.

Send the completed form(s) to the Department of Health and Ageing at the following
address:

      Approved Provider Section
      MDP 12
      Office of Aged Care Quality & Compliance
      Department of Health and Ageing
      GPO Box 9848
      Canberra ACT 2601

Your obligation to notify the Department
Division 9 of the Aged Care Act 1997 (the Act) sets out the obligations that arise from being
approved under section 8-1 of the Act. One of these obligations is to notify the Department of a
change in any of the Approved Provider’s Key Personnel within 28 days after the change
occurs.

Approved Providers have a responsibility under Part 4.3 of the Act to comply with this
obligation. Failure to comply with a responsibility can result in a sanction being imposed under
Part 4.4 of the Act.

Giving false or misleading information is a serious offence.

Key Personnel are defined in subsection 8-3A of the Act as:

(a)   a member of the group of persons who is responsible for the executive decisions of the
      entity at that time;
(b)   any other person who has authority or responsibility for (or significant influence over)
      planning, directing or controlling the activities of the entity at that time;
(c)    if, at that time, the entity conducts an aged care service:
            (i)     any person who is responsible for the nursing services provided by the
                    service; and
            (ii) any person who is responsible for the day-to-day operations of the service;
                    whether or not the person is employed by the entity;
(d)   if, at that time, the entity proposes to conduct an aged care service:
            (i)     any person who is likely to be responsible for the nursing services to be
                    provided by the service; and
            (ii) any person who is likely to be responsible for the day-to-day operations of the
                    service;
whether or not the person is employed by the entity.




March 2009                          Department of Health and Ageing                       Page 1
               This form is an approved form for the purposes of the Aged Care Act 1997
  Notification of Changes to Key Personnel

Key Personnel may change for several reasons. For example, a Deputy Director of Nursing
may become the Director of Nursing, or the Director of Nursing at one service has moved to
another service.



Other changes to the Approved Provider

Under section 9-1 of the Act, any change of circumstances that materially affects your suitability
to be a provider of aged care must be notified in writing to Approved Provider Section, MDP 12,
Office of Aged Care Quality and Compliance, Department of Health and Ageing, GPO Box
9848, Canberra 2601 within 28 days after the change occurs.

Please also advise the Department in writing if any of the name or address details of the
Approved Provider or its services change.




March 2009                     Department of Health and Ageing                          Page 2
             This form is an approved form for the purposes of the Aged Care Act 1997
  Notification of Changes to Key Personnel

     Change of role of a Key Personnel within an Approved Provider
If a current key personnel is changing roles within your organisation but will continue to be a key
personnel, then provide details of this change.




 Full LEGAL name of Approved
 Provider



 Approved Provider’s ABN




Personal Particulars of the Key Personnel who is changing roles


                                  Title   Given Name(s)                     Family Name
 Name


 Former name(s)


 Date of birth

 Previous Key Personnel
 Position




New Key Personnel Position



If position is specific to one service then please provide the following details:


Service type*                      RACS           CACP           Flexible

Service ID*


Service name*




Date Change Effective




March 2009                         Department of Health and Ageing                              Page 3
                 This form is an approved form for the purposes of the Aged Care Act 1997
  Notification of Changes to Key Personnel

APPROVED PROVIDER SIGNATURE
 Name of person signing

 Position


 Signed                                                             Date                /    /



Note: This should only be signed by those persons who are legally empowered to give
assurances and enter into contracts and commitments on behalf of the Approved Provider.


             Giving false or misleading information is a serious offence.




March 2009                     Department of Health and Ageing                              Page 4
             This form is an approved form for the purposes of the Aged Care Act 1997

				
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Description: 'NOTIFICATION OF CHANGES TO KEY PERSONNEL' FORM