South Australian Employment Tribunal

Form A68 – Application for Review (Police)

Form A68

Application for Review (Police)

Case Number
(SAET use only)

About this form

·  This is the approved form for a member of the SA Police or former member to apply for a review of a prescribed decision under the Police Act 1998 and regulations.

·  The timeframes in which this form must be lodged are detailed below.

·  Submitting an incomplete form (including any relevant supporting documents) may result in delays.

Application TYPE

Please select the type of decision you are applying to have reviewed. Please note the legislative provisions under the Police Act 1998 and the timeframe in which an application must be lodged with SAET.

Type of decision to be reviewed (Police Act 1998 reference): / Application must be lodged within:
☐ decision to terminate a member’s appointment (section 48(1)):
☐ during a period of probation (a)
☐ on a ground for termination under Part 7 (b):
☐ incapacity due to physical or mental disability or illness (section 45)
☐ unsatisfactory performance (section 46) / 28 days of receiving notice of the determination
☐ decision to transfer a member to another position (other than under Part 6 or section 46) and the member believes that he or she is being punished for particular conduct (section 52) / 14 days of receiving notice of a determination

Party details

Applicant (member)

Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
Address Street 1
Street 2
Suburb / State / Postcode
Department / Agency
Current role title / Classification
Is anyone representing you? / ☐ No ☐ Yes. Please specify:

Representative detail (if required)

Organisation
Contact First name / Last name
Email
Telephone / Mobile
Address Street 1
Street 2
Suburb / State
Postcode / Country

Decision-maker

Role
Department / Agency
Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
Address Street 1
Street 2
Suburb / State / Postcode

Reviewable DECISION details

Is a copy of the decision attached to this application? / ☐ Yes ☐ No (please provide reason why)
Date of the decision
Date you receive notification of the decision?
Are you lodging this application within the prescribed timeframes? / ☐ Yes ☐ No (please provide full reason why below)

Why do you say that the decision is wrong? Please attach any supporting documentation.

What is the outcome you are looking for?

LODGING YOUR COMPLETED FORM

☐ A copy of the decision is attached to this application

The person lodging this form must send a copy to all other party/ies.

Name of person lodging
Signature
Date

Please lodge this form, together with any accompanying documents, with the South Australian Employment Tribunal:

Email:
Post: PO Box 3636, Rundle Mall, SA, 5000
In person: Level 6, Riverside Centre, North Terrace, Adelaide, 5000

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR OWN RECORDS

www.saet.sa.gov.au

SAET Registry: 08 8207 0999