Superannuation
Complaints
Tribunal
Level 7, 120 Collins Street, Melbourne VIC 3000
Postal Address: Locked Bag 3060, Melbourne VIC 3001
Telephone: 1300 884 114
International: +61 3 8635 5580
Fax: (03) 8635 5588
Website: www.sct.gov.au
Disability Benefit complaints
C
omplainant's Name:
S
uperannuation Provider:
Education / Training / Experience / Activities Questionnaire
Below are some questions to assist the Tribunal in understanding your capacity
and activity level. Please answer all questions relevant to you. If the space is
insufficient for your answers please include additional sheet(s) and mark with
the question number(s).
1. W
hat was the highest standard of formal education that you reached?
Please indicate the level and the year you completed it.
(eg. High School year 10 1980)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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___________________________________________________________________________
2. H
ave you had any post primary/secondary formal training?
Please list course(s), levels and year completed.
(eg. Trade, TAFE, professional institutes and university studies)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
3. H
ave you undertaken any other relevant skills training, whether 'on the job',
or in relation to any work or hobby?
Please list course(s), level(s) if applicable and year completed.
(eg. 'on the job' training in building maintenance; forklift driver course; computer
course; clerical skills; hospitality course; security officer training, etc)
___________________________________________________________________________
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4. What activities at your most recent employment did you perform on a regular
basis?
Please describe the activities and indicate the periods of such activity.
(eg. Required to drive forklift 4 hours per day; accessing and processing data in
computer 1 hour, with the balance of time collating customers' orders involving
bending/twisting /climbing ladders 3m high; lifting weights up to 5 kg.)
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5. What domestic and recreational activities did you perform regularly prior to
your last day at work?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
6. What activities are you restricted in performing as a consequence of your
injury / illness relative to:
a) Your normal occupation
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
b) Domestic and recreational
___________________________________________________________________________
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7. What activities can you perform?
___________________________________________________________________________
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2
8. Is there any work that you believe you can perform fulltime on a regular
basis for which you are fitted by education, training or experience?
If "yes" please list.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
9. Please list your work history:
type of employment employer and dates of employment
10. Have you received any income or payments since your last day at work?
YES NO
a) If employed:
Name / Address of Employer
______________________________________________________________________
______________________________________________________________________
Nature of work (eg. Sales, Nursing, Driving etc):
______________________________________________________________________
Hours per week:
______________________________________________________
b) Centrelink Payments:
Nature:
____________________________ Amount per fortnight: $ _________
c) Workers' compensation :
Regular
Payments:
Date Commenced:
____/____/________
Date Ceased:
____/____/________
Amount per fortnight: $
_________________
d) Workers' compensation:
Lump Sum
Payment:
Lump Sum Amount: $
_________________
Date Received:
____/____/________
3
e) Other Superannuation Benefits:
Fund Name:
________________________________________
Amount: $_________________
Date Received:
____/____/________
Fund Name:
________________________________________
Amount: $_________________
Date Received:
____/____/________
Fund Name:
________________________________________
Amount: $_________________
Date Received:
____/____/________
f) Any Other Payments (provide copies of supporting documents):
Nature:
________________________________________
Amount: $_________________
Date Received:
____/____/________
Nature:
________________________________________
Amount: $_________________
Date Received:
____/____/________
STATEMENT
I declare that the information on this form is complete and correct.
Your signature Date
_____________________________ ____/____/________
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