Fillable Freedom of information Application for access (ReturnToWorkSA)

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Freedom of information Application for access (ReturnToWorkSA)

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The Freedom of information Application for access (ReturnToWorkSA) form is 2 pages long and contains:

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  • 10 check-boxes
  • 26 other fields

Country of origin: AUSTRALIA
File type: PDF

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Freedom of information – Application for access
Applicant details
If you are requesting information regarding your own personal information, please include details of former names and any other name you are
known by.
Surname
Given names
Postal address
Postcode
Telephone (Home)
(Work)
Email
Mobile
Access required
a) I require a copy of the information/documentation Yes No
OR
b) I wish to only inspect the information/documents Yes No
These documents contain information about:
a) Your personal affairs Yes No (If yes, complete ‘Other’ section on page 2)
b) Another person’s personal affairs Yes No (If yes, complete ‘Third party access’ section below)
c) ReturnToWorkSA Yes No (If yes, complete ‘Other’ section on page 2)
Third party access
Please provide details of the person whose information you are requesting, including former names and any other name person is known by.
(Only to be completed where personal information is being requested by a third party).
Name(s)
Address
Postcode
Date of birth (of claimant) / /
Contact phone number
Email address
Claim number(s)
Employer name (if applicable)
Please indicate the records/documentation that you require
Note: Section 26 of the Freedom of Information Act 1991 (SA) requires ReturnToWorkSA to consult directly with the person that the information
relates to before any information can be released.
Freedom of information – Application for access
Other
Please provide details of the information /documentation you require:
Please note that information can only be provided if held by ReturnToWorkSA or our claims agents.
Fees and charges applicable under Freedom of Information Act 1991
The 2021/22 applicable fee is $38.20. Please refer to our fees and charges on our website (www.rtwsa.com) for further information. You may be
entitled to access your own information free of charge under section 180 of the Return to Work Act 2014 (SA).
I am a concession card holder and request a reduction in fees and charges. Yes No (please attach a copy of your card)
Payment of the application fee can be made by:
• Cheque or money order made payable to ReturnToWorkSA.
• Via direct deposit to the below details:
BSB:
Account number:
Account name:
Payment reference:
Signature
Date
Please complete this form and return to:
ReturnToWorkSA reception 8.30am - 5.00pm
400 King Willam Street Adelaide SA
ReturnToWorkSA
GPO Box 2668
South Australia 5000
Phone: 13 18 55
Email: foi@rtwsa.com
Website: www.rtwsa.com
To contact ReturnToWorkSA in a language other than English, please
ring t
he Interpreting and Translating Centre on 1800 280 203 and ask
them to contact us on 13 18 55.
This interpreting service is available at no cost to you.
If you need information in braille, audio, e-text or large print
, please
call us on 13 18 55 and we will do our best to help you.
If you are deaf or have a hearing or speech impairment you can call
R
eturnToWorkSA through the National Relay Service (NRS):
•
TTY users can phone 13 36 77 then ask for 13 18 55.
•
Spea
k & Listen (speech-to-speech) users can phone 1300 555 727
then ask for 13 18 55.
•
Internet relay users can connect to NRS on
www.relayservice.com.au then ask for 13 18 55.
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Freedom of information Application for access (ReturnToWorkSA)

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Completed 29 July 2021

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