<p> Department of Education, Training and Employment Graduated Return to Work Timesheet CM12</p><p>Incorporating application for leave Action Required: This form should only be completed by employees participating in a graduated return to work program on: WorkCover partially funded programs; QSuper rehabilitation pension; Sick Leave. This form acts as your weekly leave application in conjunction with the Return to Work Plan. Completing it will ensure that you receive correct payments from the Department of Education, Training and Employment, WorkCover and/or QSuper. Please complete this form each Friday and send it to the claims officer in your district/region/central office. EMPLOYEE DETAILS Employee Surname: Initials: Number: </p><p>School/Location: Period of leave WorkCover (one week) Mon / / to Fri / / Claim No: </p><p>Time off to be applied for (please tick): Sick Leave QSuper benefit (no pay) WorkCover</p><p>Day Full time hours Hours scheduled to Hours actually Leave hours taken Leave Type Used (please state the be worked on Worked number of rostered rehabilitation plan hours per day worked before your injury).</p><p>Eg. 01/04/06 7.25 6 5.75 1.50 SKLV</p><p>Mon / / </p><p>Tues / /</p><p>Wed / /</p><p>Thu / /</p><p>Fri / / Total hours</p><p>SIGNATURES Employee: Date: / / </p><p>Supervisor: Date: / / </p><p>Rehabilitation & RTW Coordinator: ____ Date: / / </p><p>OFFICE USE ONLY</p><p>Hourly Rate of Pay $ Gross wages paid for period $ . . Department of Please Education, Employee Reimburse: Training and Directly Employment</p><p>Uncontrolled copy. Refer to the Department of Education, Training and Employment Policy and Procedure Register at http://ppr.det.qld.gov.au to ensure you have the most current version of this document. Page 1 of 1 Department of Education, Training and Employment Graduated Return to Work Timesheet CM12</p><p>The information I have provided is true and not misleading.</p><p>Name: Telephone No:</p><p>Signature: Date: Regional Office Location:</p><p>Leave Entered Initial Date Faxed Initial Date Registered Initial</p><p>Uncontrolled copy. Refer to the Department of Education, Training and Employment Policy and Procedure Register at http://ppr.det.qld.gov.au to ensure you have the most current version of this document. Page 1 of 1</p>