CJC contact / file no: ______ N/A / Date of activity: _____/_____ / _____
Mediator Name: ______ / Court/venue: ______

ACTIVITY (please select the activity performed below):

NOTE: Activity times for the activities listed below are to be completed on thenon-standard activity form

Conflict management(attach non-standardactivity formrecommendation report)

 Facilitation (attach non-standard activity report & recommendation report)

 Pre-mediation (attach non-standard activity report & recommendation report)

NOTE: Activity times for the activities listed below are to be completed onpage 2 of this form

 List day: (pre-trials,intake at court list days eg. small claims & AVO’s)

Community development: (presenting & promoting CJC)

Name of organisation: ______

 Other(please indicate): ______

1. Was an interpreter used? Yes No (If yes, attach interpreter receipt)

Name of interpreter: ______Time spent interpreting: ______hrs ______mins

2. Did a reportable incident occur? Yes No

Was a mishap report completed? Yes No

Brief details of incident: ______

3. Was accommodation required? Yes No

Date: _____/_____/_____Location: ______

I CERTIFY that the details show on the Non Standard Payment form are a correct record of my official movements and that the distance travelled were in connection with a bona fide official business and was necessary for the economic performance of my duties.

Mediator Signature: ______Date://

Signature is required only when posting forms to CJC

FORM TO BE RETURNED IN 7 DAYS

Community Justice Centres

Reply Paid 84744

Parramatta NSW 2150

Email:

Office Use OnlyPayments processed

Pay claim received on:Work time (9020): ______KMS (3252): ______Total travel time (1B44): ______Project Code: ______

ACTIVITY TIMES – For List Days and Community Development Only / TRAVEL TIMES – For List Days and Community Development Only
Date: // / Date: //
Arrive at venue / Time: am pm / Depart home / Time: am pm
Activity started / Time: am pm / Arrive destination / Time: am pm
Activity ended / Time: am pm / Unpaid inward travel time (Personal time) / hrs mins
Departed venue / Time: am pm / Depart destination / Time: am pm
Break (eg. lunch if appl.) / hrs mins / Arrive home / Time: am pm
*** Preparation time
(For promoting CJCs – prior approval required) / hrs mins / Unpaid outward travel time (Personal time) / hrs mins
Total activity times(Office use only) hrs mins / Total travelling times(Office use only) hrs mins

NOTE:

Pre-mediation Activity and Travel times to be recorded on the Non Standard Activity form

In General Comments below, please provide breakdown of official business travelling times if personal business was conducted during your journey (eg. stopped for shopping).

Provide details should an incident occur that results in additional travel time (eg. traffic jam, road closure).

General comments:

______

Breakdown of travel – Authorised Overnight travel

Depart Home / Date: _____/_____/_____ / Time:_____:_____ am/pm
Arrive accommodation at
______/ Date: _____/_____/_____ / Time:_____:_____ am/pm
Depart accommodation / Date: _____/_____/_____ / Time:_____:_____ am/pm
Arrive mediation venue / Date: _____/_____/_____ / Time:_____:_____ am/pm
Depart mediation venue / Date: _____/_____/_____ / Time:_____:_____ am/pm
Arrive at accommodation / home / Date: _____/_____/_____ / Time:_____:_____ am/pm
Any meals taken in above? / Date: _____/_____/_____
Time spent: ______/ Time:_____:_____ am/pm

Travel Diary – Mileage claim only - Authorised Day/Overnight travel

Date / Departure / Arrival / travelled
Use of
Location / Time / Location / Time / Car
TOTAL(S) KMS
Motor Vehicle Allowance - Odometer Reading
Start odometer reading / km
End odometer reading / km
Total Distance / km

REMEMBER TO:

  • Mileage only applies if travelled more than 100kms one way
  • Google maps must have the address from base to base!
  • If Google maps don't pick up the extra kms you are claimingyou must also include the odometer reading
  • Enter odometer reading before commencing travel and ending travel
  • Mileage casual business rate is 0.264 as at August 2016

CJC mediator non-standard pay form – March 2017Page 1