Notification type

Is this form being used to register, update or to discontinue service? *

New residenceUpdated residenceDiscontinued residence

Details of residence

Name of group home

 

Street address (including street number) *Apartment/Unit number (if applicable)

City *

StatePlease selectNSW

Postcode *

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

On-site contact phone number *A phone number that will always be answered on-site in-case of an emergency.

Type of residence *Single dwelling (i.e. house)Boarding house, guesthouse or hostel (Class 1b ≤ 300 m² and ≤12 residents)Building containing 2 or more separate Sole Occupancy Unit (SOUs) (Class 2)Boarding house, guesthouse, hostel, hotel or backpacker accommodation (Class 3)

Construction *Full brick or masonryWeatherboardFibro-sheetConcrete panel (e.g. pre-cast walls) Lightweight panel or claddingOther

Number of storeys *1234+

Fire safety equipment *

Smoke or heat detectorFire extinguisherFire sprinkler systemHose ReelFire Panel (Monitored by external provider)Fire Panel (Unmonitored)None of the above

Details of occupancy

Number of residents *

Number of staff *

The residence must have at leased one staff member on-site at all times to be classified as a Group Home.

Indicate any risk type or special needs *

Non-ambulatory (not able to walk)Critical medical equipmentNot able to communicateChallenging / Resistant behaviourNon-English speakingHard of hearingVisually impaired (blind)None of the above

Submitted by authorised service provider

Company *

Name *

Email address *

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