ACAC CCM 036 Dignity of Risk Assessment Form V2.0

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Client & Assessment Details

Basic info — select or type where needed.

Client Full Name *

Assessment Date *

ACAC Staff *

Job Title

Participants

Client Representative (if present) Family member or support person

Power of Attorney / Guardian (if applicable)

⚠️

Risk Identification

Tap to answer — only add notes where prompted.

Risk is part of an existing activity or behaviour? Something the client already does

Yes No

What has changed to make this a risk now?

Risk relates to a new desired activity or goal? Something the client wants to start

Yes No

Describe the desired activity or goal

Risk applies to *

🧓 Client

🏥 ACAC Employee

🏘️ General Public

👥 Other

Type of potential harm *

🦴 Physical

🧠 Psychological

💰 Financial

Nature of the risk *

Assessed risk level

Brief description of the risk * How does this pose a risk? (injury, emotional harm, financial loss, etc.)

Client's reason for taking this risk * Why does the client want to continue or pursue this?

Capacity & Evaluation

Client has capacity to carry out this activity safely?

Yes No Unclear

Client is aware of the dangers involved?

Yes No

Client can manage or respond to those dangers?

Yes No Partially

Mitigation strategies discussed

📋

Outcome & Agreement

Document what was agreed and next steps.

Client is aware of the risk identified?

Yes No

Guardian / POA made aware of risks? Only if applicable

Yes No N/A

Agreed to explore risk in original or modified form?

Original Modified Not Agreed

Describe the modification

Reason client did not agree *

⚠️ Next required step

Because the client has not agreed, you must complete a Service Refusal & Risk Acknowledgement — CCM 020. This documents the client's informed refusal and protects both the client and ACAC under the Aged Care Act 2024.

Additional referral or assessment required?

Yes No

Referral details

✅ Agreed Risk Mitigation Strategies

⚠️ Risk Not Reduced — Client Taking Responsibility (ACAC not involved)

Post-implementation review *

VC review note added?

Yes Not yet

✍️

Approval & Sign-off

Capacity check, documentation tick-off, sign.

Client has capacity to understand the decisions and risks?

Yes No

Action taken regarding capacity

Guardianship / POA paperwork sighted?

Yes No N/A

Documentation Checklist

Care Plan updated
Visual Care updated and all documents saved
Dignity of Risk Acknowledgement Form (CCM 036) completed and saved to VC

Client Signature

Client draws signature below * Use finger on touchscreen or mouse on desktop

✏️ Draw signature above

Staff Sign-off

Staff Signature *

🖊 Click to sign

Date *

⚠️ Data handling reminder

Sensitive client information — Privacy Act 1988 & Aged Care Act 2024. Save directly to Visual Care only. Do not email or share outside ACAC systems.