This form is to be used to request recognition of prior service for personal (sick) leave and long service leave purposes. The Department requires the information collected on this form to determine an individual’s entitlements. For information about the Department’s policy on recognition of prior service, see:

Privacy: The information collected on this form is for the purpose set out above and is required to process your request. Your information will not be disclosed without your consent or unless authorised or required by law. You are able to request access to the personal information that the Department holds about you and request that it be corrected by contacting your Principal/Manager. Information about contacting the People Division is available at: Information about the Department’s privacy policy is available at:

Employee details

Family Name: / Given Name(s): / Employee ID:
School/Work Unit Name: / Division/Region (if applicable):

Supporting Documentation

Original Statements of Service from previous employers must be provided on official letterhead and include the information specified below (note: dates must include day, month and year). The principal/manager must sight the original documents supporting this request.
Tick all boxes confirming that the required information is provided as set out below:
Employment start and end dates and the reason for cessation of employment
Time fraction worked and details of any changes in time fraction - include date of change and the time fraction worked (e.g. 0.5, 0.7, 1.0, full-time)
Start and end date of any unpaid leave. If no leave without pay was taken this must be stated
When requesting recognition of casual employment, dates and total hours worked must be provided
Personal (sick) leave accrual balance on cessation of employment and the date that the next allocation of (personal) sick leave was due
Details of Long Service Leave used, including details of any payment of unused Long Service Leave upon termination (if applicable)

Declaration by employee

I declare that the information I have provided in support of this request is true and correct.
Employee’s Signature: ______Date: ______/ ______/ ______

Declaration by Principal/manager

I declare that I have sighted the original documents supporting this request and the accompanying documents are true copies of the original documents.
Principal/Manager’s Signature:______
Principal/Manager’s Name (please print): ______Date: ______/______/______
Once completed, provide the form, with a copy of each Statement of Service (do not send original documents) to:
  • Schools People Services for teaching service employees; or
  • Corporate People Services for public service employees.

Form name goes herePage | 1