26.7.5 Smoking Questionnaire

Cigarette Smoking Questionnaire - SRCA

This form is in connection with your claim for pension and medical treatment and the information you supply will assist in deciding eligibility for benefits under the Safety, Rehabilitation and Compensation Act 1988 (SRCA).   In the event of an appeal against a decision, this information may be provided to the Administrative Appeals Tribunal or to the Federal Court.

Claimant's Details

Report Details

1.Have you ever smoked cigarettes on a regular basis?

❏No - Please sign the form and return it to the Department

❏Yes

2.When did you first start smoking cigarettes on a regular basis? (You may not know exactly when you started to smoke cigarettes regularly, but please be as precise as possible. Please state the day, month and year if known).

3.Why did you start to smoke cigarettes on a regular basis?

4.Have you ever stopped smoking permanently?

❏No

❏Yes - When did you stop smoking permanently?

Claimant's Signature

You are reminded that:

• The Declaration you signed on the claim form also covers the information you supply on this form.
• There are penalties for knowingly making false or misleading statements.