Forms and templates

Registered service providers reporting

Currently the NIISQ Agency is reviewing and improving the reporting requirements for registered providers. Advice will be provided regarding these reporting requirements as soon as they become available.

My Care and Support Agreement

The My Care and Support Agreement template is a tool to facilitate open and collaborative conversation between an attendant care and support service provider and the NIISQ participant to discuss and record mutual expectations for the delivery of services and create a strong foundation for a successful care delivery. It is aimed to promote active inclusion, participation and decision making by NIISQ Participants related to their injury related care.

This template is optional, and a service provider may choose to utilise their own templates to scaffold this process.

Forms for Providers

Service providers can access these forms to provide information to the NIISQ Agency. If you need access to a form that is not on this website, please contact NIISQ Agency on 1300 607 566 or enquiries@niis.qld.gov.au.

Financial

• Vendor Creation or Change Form – Service Providers

  This form is used to set a service provider up as an approved vendor in the NIISQ Agency accounts system.

  Vendor creation or change form – Service providers (.pdf)

Hospital discharge

• Discharge services request form

  The discharge treating team may choose to use this request form to assist with discharge planning for NIISQ participants.

  Discharge services request form (.pdf)

Equipment and consumables requests

• Accepted injury-related pharmaceutical or medications form

  This form is to assist doctors to provide the NIISQ Agency with information required to fund accepted injury-related pharmacy or medication needs.

  Accepted injury-related pharmaceutical or medications (.pdf)

  Accepted injury-related pharmaceutical or medications (.docx)

  Additional Accepted injury-related pharmaceutical or medications (.pdf)

   

• Equipment Requests

  This form can be used by providers prescribing aids and equipment (assistive technology) for NIISQ participants.

  Equipment request form (.docx)

• Continence and consumables

  The form enables providers to clinically justify and list the prescription of items required for:
  
  – Continence
  – Skin integrity and wound management
  – Respiratory and ventilation needs
  – Nutritional needs.

  Continence and consumables request form (.pdf) 

  Continence and consumables request form (.docx)

Assessments and reports

• Care and Needs Scale (CANS) template

  The CANS is a standalone assessment for care needs used for participants with a traumatic brain injury (TBI). It’s a standardised assessment designed by respected neuropsychologist Professor Robyn Tate who has extensive clinical experience in rehabilitation after traumatic brain injury.

  The CANS was created to address a gap in the availability of a psychometrically sound measure that could capture the unique type of support needs experienced by people with TBI. We use a participant’s CANS score to inform the overall needs assessment. Although specifically designed for participants with TBI, we may use a CANS score for other participants—such as those with a spinal cord injury—to help provide a benchmark for care needs.

  Care and Needs Scale (CANS) template (.pdf)

• Vocational rehabilitation suitable duties form

  This form is used to provide information when a participant wishes to return to work. This information assists the NIISQ Agency to work with the participant and their employer to develop a return to work plan.

  Vocational rehabilitation suitable duties form (.pdf)

• Home modification functional assessment report

  Approval and prior discussion with the NIISQ Agency are required before providing advice regarding a NIISQ participant’s major or minor home modification needs.

  To request a copy of the NIISQ Major Home Modification Advisory Report and Companion Guide and NIISQ Minor Home Modifications Advisory Report and Companion Guide, please contact modifications@niis.qld.gov.au.

  For further details, refer to the Necessary and Reasonable Guidelines available on the NIISQ website, 10. Home modifications – National Injury Insurance Scheme, Queensland

• Allied health treatment plan and report

  This form can be used by allied health providers to communicate outcomes of treatment, future treatment goals and clinically justify recommendations.

  Allied health treatment plan and report (.docx)