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Quarterly report on progress towards eligibility to provide care for residential care placesApproved providers must lodge this report every 3 months from the date of provisional allocation, in accordance with the condition of allocation. Approved Providers are requested to include specific information, including dates of activities when completing this form.
This form has three parts:- Part A must be completed if this is the first quarterly report since the
provisional places were allocated. - Part B must be completed if you have previously submitted quarterly reports
in relation to the same provisionally allocated places.- Part C must be signed by all approved providers.
Name of approved provider:
Physical address of approved providerStreet address: Suburb: State: Postcode:
Key personnel for this reportTitle: Given name(s): Family name: Position: Contact phone: Email address:
Service ID:
Name/proposed name of service:
If you have any questions about completing this form, please phone 1300 653 227 and ask for aged care services in your state or territory office. If you require more room, please attach additional pages. Please ensure that any additional pages are clearly labelled with your details and refer to the specific question.
Note: You may be contacted by the Department to discuss your application.
The Department may, at its discretion, request documentation to support your claims.
Part A – must be completed if this is the first quarterly report since the provisional places were allocated
A1. Please provide details of the provisionally allocated places.
Date provisional allocation was made
Number of places
Current expiry date of the provisionally allocated places
Are these places linked to a capital grant for construction or redevelopment?Y/N
Are these places linked to a Zero Real Interest Loan for construction or redevelopment?Y/N
dd/mm/yyyy dd/mm/yyyy
dd/mm/yyyy dd/mm/yyyy
dd/mm/yyyy dd/mm/yyyy
Total places
A2. Is there either planned or current construction of premises for the residential care places?
Yes Please go to A3.
No Please go to A4.
A3. Which of the following existing places will the construction activity affect?
Number affected
Operational places
Offline places
Total places
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A4. Please describe any changes to development plans that have occurred since the places were allocated to you.
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Milestones The following questions relate to your progress against the following milestones: finance, land, planning, and construction. When completing these questions please include specific information, including dates of activities.
FinanceA5. Has finance been approved?
Yes Date finance was approved: dd/mm/yyyy Please go to A7.
No Please go to A6.
A6. Please provide a summary of any delays in acquiring finance for the development. Please state the actions taken to remedy any delays, including dates and specific activities undertaken.
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Land A7. Has land for the development been acquired?
Yes Please go to A9.
No Please go to A8.
A8. Please provide a summary of any delays in acquiring land for the development. Please state the actions taken to remedy any delays, including dates of your activity.
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Planning A9. Please provide a summary of any delays in finalising planning milestones including the lodging and approval of development applications, planning permits, building applications and building permits. Please state the actions taken to remedy any delays, including dates and specific activities.
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ConstructionA10. Please provide a summary of any delays in finalising construction milestones, including calling for tenders, the signing of building contracts, and the commencement and completion of building work. Please state the actions taken to remedy any delays, including dates of your activity.
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A11. Have there been any other delays not mentioned in any of the above milestones that have prohibited the progress of the residential aged care development? Please state the actions taken to remedy any delays, including dates of your activity.
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Part B – to be completed if quarterly reports have previously been submitted in relation to the same provisional places
B1. What progress have you made towards being in a position to provide care in respect of the provisionally allocated places since your last quarterly report? When completing this question please include specific information, including dates of activities.
B2. Have there been any delays in your progress?
Yes Please go to B3.
No Please go to Part C.
B3. Please provide a summary of each delay and state the actions taken to remedy them.
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Part C – Declaration – All applicants to sign
This report must be signed only by those persons who are legally authorised to sign for and on behalf of the approved provider. A person who gives information to a Commonwealth entity, or to a person exercising powers or performing functions under, or in connection with, a law of the Commonwealth, or who gives the information in compliance or purported compliance with a law of the Commonwealth, and does so knowing the information is false or misleading, or omits any matter or thing without which the information is misleading, may be guilty of an offence under the Criminal Code Act 1995.
I/We declare that all the information set out in all sections completed in this report, and any associated attachments, is true and complete.
I/We declare that the key personnel in my/our service are, and will continue to be, suitable to provide aged care and are not disqualified individuals.
I/We consent to the Secretary of the Department of Social Services obtaining information and documents from other persons or organisations, including the Australian Aged Care Quality Agency and state, territory and Australian Government Departments/authorities, to assist in assessing the report.
Name:______________________________________________________________
Position:____________________________________________________________
Signature:_______________________Date:________________________________
Name:______________________________________________________________
Position:____________________________________________________________
Signature:_______________________Date:________________________________
Please send the completed form to the Department
By post: Aged Care BranchDepartment of Social ServicesGPO Box 9820In the capital city of the state or territory in which the aged care service is located.
By email: To the state office in which the aged care service is [email protected]; [email protected]; [email protected]; [email protected]; [email protected]; [email protected]; [email protected].
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If you have any questions about completing this form, please phone 1300 653 227 and ask to speak with a Departmental Officer in aged care in your state or territory office
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