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25 Year Service Medallion Request Form(Central Office only)
Officers having completed a total of 25 years or more recognizable service with the Queensland Government are eligible for a 25 year service medallion. Where practical, presentation of medallions is encouraged to coincide with significant events such as State Education Week (May/June), Teacher Aides’ Day (Sept), World Teachers’ Day (Oct), end of term or at retirement etc. Allow time for engraving prior to presentation. (PLEASE COMPLETE CLEARLY AS SOME QUALITY IS LOST DURING FAXING.)
PRIVACY NOTICE: The information being collected via this form is for the purpose of processing requests for employee service recognition. Personal details will not be disclosed to any other third party without the employee’s consent, or unless authorized or required to do so by law. All personal information collected by the Department is handled in accordance with the Information Privacy Act 2009.
1. EMPLOYEE DETAILS: (please attach additional pages if required)
Employee Number / First Name / Last Name / Position & Central Office work unit / Start Date
with Qld Govt / Has a 25 yr medallion been issued before? / Nominee is happy to accept now
Yes
No / Yes
No
Has the above officer/applicant taken leave without pay or resigned for a period greater than 3 months at any time? Yes No
2. ADDRESS FOR DELIVERY OF MEDALLION (must be to requesting work unit for engraving – cannot be sent directly to the award recipient):
Attention: ______
Address: ______
______
______Pcode ______/ 3. PRESENTATION DETAILS:
DATE (if known): _____/_____/_____
Where no date is indicated, medallions will be supplied as soon as possible.
Where a date is provided, every effort will be made to supply in time provided all “checks” have been completed and sufficient prior notification has been allowed (recommend min. 3 weeks).
4. RECIPIENT’S ENDORSEMENT:
In accordance with Privacy legislation, I agree or do not agree to my name and location details being released to the media for promotional purposes if required. Further, I am or am not happy for this award to be presented to me through a Member of Parliament (which may include media).
Signature: ______Work Unit name : ______Date: _____/_____/_____
5. SUPERVISOR’S ENDORSEMENT:
I support this nomination for a service medallion.
Signature: ______
Signed (printed): ______
Position: ______
Branch: ______
Date: _____/_____/_____ / (MANDATORY REQUIREMENT)
6. DIRECTORor ADG APPROVAL: I recommend the officer/s nominatedto receive a service medallion once eligibility has been confirmed through HR.
Signature: ______
Branch: ______
Date: _____/_____/_____
Forms with no signature in this field will be returned to the originator to complete the approval process.
Service Verification checks are performed by the Ethical Standards Unit - Workforce Futurescan arrange these checks.
Work Units need to allow time for these checks as well as medallion engraving prior to presentation.
5. SERVICE RECORD VERIFICATION:
Service Duration confirmed + Disciplinary Action checks clear = Eligibility confirmed
I certify that Ethical Standards Unit has verified the accuracy of service records for this nominee, disciplinary action is not pending and unless indicated, the nominee meets the eligibility criteria.
Signature: ______- Workforce Futures Date: ____/____/____
Once signed by your DIRECTOR/ADG, fax toWorkforce Futureson 3237 0842
TRIM: 10/179574 Date despatched: