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N part D. Part A Employee details Mr/Mrs/Ms/Miss/Dr/other (please specify) Surname Given names Date of birth (dd/mm/yyyy) Payroll number QSuper claim number Standard hours per fortnight Fortnightly superannuable salary $ Substantive position Fax number Email address Fax number Email address 1 Including superannuable allowances Part B Employer details Department Rehabilitation and return to work coordinator Phone number Supervisor Phone number Part C Program details Program goal.

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