External

          BIU use only

Ref No:

Sent to ISG

Completed

AD HOC REPORT REQUEST

When fully completed, this request should be emailed to the Business Information Unit by or through a senior officer (such as a Team Leader or National Business Manager or above). If there is insufficient space on this form, please provide an attachment.

Requested by:

State/Division/Unit:

Contact phone/fax:

Phone:Fax:

Date of request:

Date report required:

Purpose of report:

Who will use/see the report:

Selection criteria:

(eg all open accepted, stress claims for AQIS in NSW with a DOI after 1/7/89)

List data fields required:

(eg claim number, claimant name)

Time period report covers?

(specify financial years; date of injury or date received, determined)

From:To:

Any other comments/specifications:

Please contact the Operations/PRACSYS Help Desk if you have any queries.

July 96