S180 Application for access
Return to Work Act 2014
Details of Application
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
Phone (Home) (Work)
Email Mobile
another person’s personal affairs
If yes to b), please complete the consent form below
Consent form
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).
I (Name)
of (Address)
Postcode
Contact phone
Authorise (Applicant’s name)
of (Address)
Postcode
to access
(Please provide details of
information/documentation)
Signature Date
a)
I require a copy of the information/documentation
OR
b)
I wish to only inspect the information/documentation
Yes
Yes
These documents contain information about:
a) my personal affairs
Yes
No
b)
Yes No
ABN 83 687 563 395
Access required (continued)
(This information must be completed to identify the worker.)
Claims files (Claim number/s) Date of birth
Please indicate the records/documentation that you require:
Please note that information can only be provided if held by ReturnToWorkSA or its agents.
Section 180 states:
Workers right of access to claims file
(1) Subject to this section, the Corporation or a delegate of the
Corporation must, at the request of a worker
(a) provide the worker, within 45 days after the date of the request,
with copies of all documentary material in the possession of the
Corporation or the delegate relevant to a claim made by the
worker; and
(b) make available for inspection by the worker (or a representative
of the worker) all non-documentary material in the possession
of the Corporation or the delegate relevant to a claim made by
the worker.
(2) Non-documentary material is to be made available for inspection
(a) at a reasonable time and place agreed between the Corporation
or delegate and the worker; or
(b) in the absence of agreement—at a public office of the
Corporation or delegate nominated by the worker at a time
(which must be at least 45 days, but not more than 60 days,
after the request is made and during ordinary business hours)
nominated by the worker.
(3) However, the Corporationordelegate isnot obliged to provide copies
of material, orto makematerial available for inspection bytheworkerif
(a) the material is relevant to the investigation of suspected
dishonesty in relation to the claim; or
(b) the material is protected by legal professional privilege; or
(c) the disclosure of the material could reasonably be expected
to endanger the life or physical safety of any person.
(4) A worker who is aggrieved by a decision under subsection (3) is
entitled to a review of the decision by the Corporation or the delegate
(as the case may be).
(5) An application for review under subsection (4)
(a) must be made in accordance with the regulations; and
(b) must be made within 30 days after the day on which notice of
the decision was given to the worker or within such longer
period as the Corporation or delegate may allow.
(6) On an application for review, the Corporation or delegate may
confirm, vary or reverse the decision under review.
(7) If the Corporation or delegate fails to make a decision on a review
under subsection (6) within 14 days after the application for review
is received under subsection (5), the Corporation or delegate will be
taken to have confirmed the decision under review.
(8) A worker who is aggrieved by a decision under subsection (6) may
apply to the Ombudsman for a review of the decision.
(9) An application for a review under subsection (8)
(a) must be made in a manner and form determined by the
Ombudsman; and
(b) must be made within 30 days after the day on which notice of
the decision was given to the worker or within such longer
period as the Ombudsman may allow.
(10) The Ombudsmanmay, in relation toareview under subsection (8)—
(a) exercise th
e powers of the Ombudsman under the Ombudsman
Act 1972 as if carrying out an investigation under that Act,
subject to such modifications as may be necessary, or as may
be prescribed; and
(b) at the conclusion of the review confirm, vary or reverse the
decision under review.
(11) For the purposes of a review of a decision of a self-insured
employer under subsection (8), the self-insured employer will be
taken to be an agency to which the Ombudsman Act 1972 applies.
(12) Section 17(1) of the Ombudsman Act 1972 does not apply in
relation to a review under subsection (8).
(13) It will be taken to be a condition of registration as a self-insured
employer that the employer will comply with any decision of the
Ombudsman that relates to the employer under subsection (10).
(14) If the Ombudsman becomes aware that a self-insured employer
has failed to comply with a decision of the Ombudsman that relates
to the employer under subsection (10), the Ombudsman must advise
the Corporation of the failure.
(15) If the Corporationoradelegate of the Corporation mistakenly
prov
ides material toaworker to which the workeris not entitled, the
workermust return thematerial within areasonable time after requested
to doso bythe Corporationorthedelegate. Maximum penalty: $2 500.
(16) In this section, a delegate of the Corporation includes a self-
insured employer.
Please complete this form and send to:
ReturnToWorkSA
GPO Box 2668
South Australia 5000
Phone: 13 18 55
Fax: 08 8233 2466
Email: foi@rtwsa.com
Website: www.rtwsa.com
To contact ReturnToWorkSA in a language other than English,
please ring the 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 any 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 ReturnToWorkSA through the National Relay Service (NRS):
TTY users can phone 13 36 77 then ask for 13 18 55.
Speak & 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.
Signature Date