WDFApplicationForm

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					UTS: WORKPLACE DISABILITY FUND
APPLICATION FORM
THIS SECTION TO BE COMPLETED BY THE STAFF MEMBER:

Are you eligible for assistance from the JobAccess Employment Assistance Fund (EAF)?
    Yes – if yes, please apply to the EAF.
    No – if no, please continue filling out this application.
If unsure, see www.jobaccess.gov.au or contact the UTS Equity & Diversity Officer
(Disability) on ph 9514 1084 or email equity@uts.edu.au for more information.


Applicant’s Details:
Name:




Faculty / Unit / Institute:




Job Title / Description:




Work Pattern:
    Full Time
    Part-time (please state hours per week:         )
    Permanent
    Casual / Contract (please state when contract expires:      )




Work Ph:                                       Fax:

Mobile Ph:                                     Home/Other Ph:

Email Address:

Best time to contact you by phone:




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Please describe your Disability (attach medical evidence if appropriate):




Have you applied for compensation in regards to this disability?
   Yes
   No


How did you hear about the Workplace Disability Fund ?




Details of Funding Request:
Please describe the type of adjustment/s required:




How the adjustment/s will assist you to perform the inherent requirements of your job:




Total cost of adjustment/s required (please attach quotes / invoice / or evidence-based
projection):




                                                                                          2
All UTS staff are requested to complete the confidential UTS EEO Data form online at
www.neo.uts.edu.au under “UTS Employee Self-Service” > “My EEO Data”
If you have not already done so, please fill out the EEO Data form. The information you
provide will help us to implement fair and equitable personnel policies and strategies to meet
the needs of all our staff. No data is used in a way which identifies individuals. Only
designated staff from HRU and E&DU have access to this data.
Have you completed a UTS EEO Data Collection Form?
   Yes
   No




Applicant’s Declaration:

        I declare that the above information is true and correct.
        I give permission for the Equity & Diversity Unit to discuss this application with my
         manager/supervisor.
        I understand that items paid for by the Workplace Disability Fund are for my use (as
         the applicant) during my employment at UTS.
        I understand that any items purchased under the Fund remain the property of the
         Equity & Diversity Unit. Should my employment within UTS cease, the item/s will be
         returned to the E&DU for reallocation or sale. Should I wish to purchase the item/s
         on leaving UTS, I may request to do so at a market value determined by UTS.




Applicant’s Signature: _____________________________ Date: __________________




If you have any questions about the Fund or require assistance with this form
please contact the UTS Equity & Diversity Officer (Disability) on ph 9514 1084 or
email equity@uts.edu.au




                                                                                                 3
THIS SECTION TO BE COMPLETED BY THE SUPERVISOR/MANAGER:


Supervisor / Manager’s Details:


Name:




Faculty / Unit / Institute:




Job Title / Description:




Work Ph:                                   Fax:

Mobile Ph:                                 Other Ph:

Email Address:

Best time to contact you by phone:




Do you agree that the adjustment/s being sought will benefit the employee’s ability to
perform the inherent requirements of their job, and/or would assist them participate more
fully beyond the performance of their basic duties?
    Yes
    No
    Not sure




Do you have any comments regarding the application? Attach a separate page if necessary.




                                                                                            4
I understand that the Workplace Disability Fund can provide funding to a maximum of
$2,000. If adjustments to a value greater than $2,000 are being sought, the work area
agrees to cover the difference.
   Yes
   No




Supervisor / Manager’s Declaration:
        I understand that items paid for by the Workplace Disability Fund are for the use of
         the applicant during their employment at UTS.
        I understand that items paid for by the Fund remain the property of the Equity &
         Diversity Unit. Should the applicant’s employment within UTS cease, the item/s will
         be returned to E&DU for reallocation or sale. Should employees wish to take the
         item/s with them after they leave UTS, they may request to purchase them from
         E&DU at a market value determined by UTS.




Supervisor’s Signature: ____________________________ Date: __________________




If you have any questions about the Fund or require assistance with this form
please contact the UTS Equity & Diversity Officer (Disability) on ph 9514 1084 or
email equity@uts.edu.au




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