2010 Request Form – 5, 10 and 20 year Milestones onlyCLOSING DATE FOR APPLICATIONS TO REGIONAL OFFICES: 31 August 2010Submit your Request Form to your Regional OfficeWhen preparing requests, please refer to the Teacher Excellence Career Milestones Guidelines.

TEACHER’S NAME: / Employee No.
Teacher Regn No. / Expiry date:
Substantive teaching position and work location:
Current position and work location (if different from above):
Address of current work location:
Contact details: / Phone (W): / Other:
Preferred email address:
Basis of employment: / Permanent Temporary / Employed under the Qld Teachers’ Award / Yes No


DETAILS OF MILESTONE BEING CLAIMED:

NOTE: Milestone lapel pins are not available for other than 5, 10 or 20 years but the 25 year service medallion is available to all departmental employees.

Calculate your eligibility:
STEP 1: This year 2010 MINUS (Year commenced as a teacher) _____ = _____ years
eg: 2010 - 2005 5
STEP 2: Have you taken any leave without salary? Yes No
If Yes, list approx. periods of time: ______
Total approx. time without salary: ______ years
STEP 3: Calculate:
No. of years above (Step 1) ____ MINUS (leave without salary – Step 2) _____ = _____ recognisable service
5 year lapel pin / 10 year lapel pin / 20 year lapel pin / 25 year medallion

In accordance with Privacy legislation, I agree / do not agree to my name and location details being released to the media for promotional purposes if necessary.

Teacher’s signature: ______Date: _____/_____/_____

Principal’s signature – supporting this request: ______

Name (please print): ______Date: _____/_____/_____

______

REGIONAL PROCESSING

SERVICE RECORD VERIFICATION: (boxes must be ticked)

Service duration confirmed + Disciplinary action - clear = Eligibility confirmed

I certify that service records for this employee are verified as correct, no disciplinary action is pending and unless indicated, the eligibility criteria has been met.
Signature: ______Name (please print): ______

Region: ______Date: ____/____/____

______

RD APPROVAL: (MANDATORY REQUIREMENT)

I recommend this officer’s request for a Teacher Excellence Career Milestone or 25 year service medallion as indicated.

Signature: ______Region: ______

Name (please print): ______Date: _____/_____/_____
____________

REGIONAL OFFICES:

·  Teacher Excellence Career Milestones are processed in bulk once annually per Region only.

·  Regions have been provided with an Excel spreadsheet for use when compiling one Regional list of requests for pins.

·  Once the Regional List has been approved by the RD, the list to be submitted to Workforce Futures by 30 September 2010.

·  Individual forms will not be accepted in Workforce Futures and will be returned to Regions for processing and adding to the Regional list.

·  Requests for Teacher Excellence Career Milestones will not be processed at any time during the year other than in conjunction with World Teachers’ Day.

TRIM: 10/150374
To discuss eligibility/service duration, please phone your Regional Office.

·  Fax completed Request Forms directly to your Regional Office by 31 August.

Centre Name / Phone Number / Fax Number
Central Queensland Region / (07) 4951 6800 / (07) 4951 6824
Central Coast District Office / (07) 4971 3600 / (07) 4971 3699
Central Queensland District Office / (07) 4938 4661 / (07) 4938 4921
Central West District Office / (07) 4658 4599 / (07) 4658 4529
Mackay-Whitsunday District Office / (07) 4951 6800 / (07) 4951 6824
Darling Downs South West Region / (07) 4616 9111 / (07) 4616 9103
Roma District Office / (07) 4622 9711 / (07) 4622 2559
The Downs District Office / (07) 4616 9111 / (07) 4616 9101
Toowoomba District Office / (07) 4616 9111 / (07) 4616 9102
Warwick District Office / (07) 4661 0500 / (07) 4661 0525
Far North QLD Region / (07) 4046 5222 / (07) 4046 5200
Cairns Coastal District Office / (07) 4046 5222 / (07) 4046 5200
Torres Strait and Cape District Office / (07) 4046 5254 / (07) 4051 3160
Tablelands-Johnstone District Office / (07) 4091 0800 / (07) 4091 4957
Metropolitan Region / (07) 3422 8352 / (07) 3422 8344
Brisbane Central and West District Office / (07) 3350 7866 / (07) 3350 7890
Brisbane North District Office / (07) 3350 7866 / (07) 3350 7894
Brisbane South District Office / (07) 3422 8655 / (07) 3422 8300
Moreton East District Office / (07) 3280 1665 / (07) 3280 1048
Moreton West District Office / (07) 3280 1613 / (07) 3280 1048
South East Brisbane District Office / (07) 3422 8317 / (07) 3349 8647
North Coast Region / (07) 3881 9600 / (07) 3881 9650
Sunshine Coast North District Office / (07) 5470 8900 / (07) 5470 8909
Sunshine Coast South District Office / (07) 3881 9600 / (07) 3881 9640
Wide Bay North District Office / (07) 4154 0300 / (07) 4153 1212
Wide Bay South District Office / (07) 4121 1614 / (07) 4121 1711
Wide Bay West District Office / (07) 4162 9500 / (07) 4162 9523
North QLD Region / (07) 4726 3111 / (07) 4726 3100
Mount Isa District Office / (07) 4744 8222 / (07) 4744 8201
Townsville District Office / (07) 4726 3111 / (07) 4726 3100
South East Region / (07) 5562 4888 / (07) 5562 4800
Gold Coast District Office / (07) 5562 4888 / (07) 5562 4800
Logan-Albert Beaudesert District Office / (07) 3804 9666 / (07) 3807 4943