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Any details you provide will be kept confidential. We will at no point contact your employer without your permission.

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- First name*
- What is the best phone number to contact you on?*
- What is your residential post code?*
- Gender: How do you identify?*
  - Woman
  - Man
  - Non-Binary
- Do you identify as any of the following?*
  - First Nations Person
  - Aboriginal
  - Torres Strait Islander
  - None
- Do you identify as having a..?*
  - Non-English-Speaking Background
  - English-Speaking Background
- What is your first language spoken?
- Do you require the assistance of a translator?
  - Yes
  - No
  We can organise a translator for you.
- Which language do you require?
- Do you identify as having a disability, including any mental health conditions such as depression or anxiety?
  - Yes
  - No
- If you answered yes, which of these apply to you?
  - Physical
  - Sensory
  - Psychiatric (including any mental health conditions such as depression or anxiety)
  - Neurological
  - Cognitive
  - Intellectual
- Last name*
- What is your personal email address?*
- How old are you?*
- Date of birth*
  DD slash MM slash YYYY
- Where do you work? (Business Name)*
- How many people does the business employ?*
  - 1 - 15 employees
  - 15 - 25 employees
  - 25 - 50 employees
  - 50 + employees
  - 100 + employees
  - 250 + employees
  - 500 + employees
  - 1000 + employees
  - Unsure
- What is your position within your workplace?
- How long have you worked at this workplace?*
- What is/was your employment status?*
  - Full time
  - Part time
  - Casual
  - Fixed Term Contract
  - Independent Contractor
- Are you still employed at this workplace/company/organisation?
  - Yes
  - No
  - Unsure
- What was the date of your dismissal/termination?*
  DD slash MM slash YYYY
  
  Please note: If you have been unfairly dismissed, you have 21 days from the date of dismissal to make an unfair dismissal application. For more information about this visit: https://www.fairwork.gov.au/ending-employment/unfair-dismissal
- What is your hourly rate of pay or rough annual salary?*
- Do you know the relevant award or enterprise agreement governing your employment?
  - Yes
  - No
  - Unsure
- Which award or agreement governs your employment?
- Are you a union member?*
  - Yes
  - No
  - Unsure
  To find out more about your relevant union visit: www.actu.org.au
- What Union are you a member of?
  If you are a union member and you have a workplace issue, we encourage you to contact your union.
What is happening at work that you would like assistance with?
For example; I was dismissed yesterday and I think it is unfair or I have been underpaid or I am being bullied at work. Please let us know if there are any deadlines that we should know about.
How did you find our service?
ie. Fair Work Ombudsman, a friend, google

We acknowledge that the Kaurna people are the traditional and continual custodians of the land upon which we carry out our work. We pay our respects to Elders past and present. First Nations’ sovereignty has never been ceded, this always was and always will be Aboriginal land.

We welcome diversity and provide a safe space for workers from all walks of life.

Read our Diversity Statement.

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$3M

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