OCCUPATIONAL SAFETY AND HEALTH REGULATIONS 1996

Western Australian Consolidated Regulations

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OCCUPATIONAL SAFETY AND HEALTH REGULATIONS 1996 - SCHEDULE 2

Form 1 — Notification of injury

[Regulation 2.4(2)]

Occupational Safety and Health Act 1984

WorkSafe Western Australia Commissioner
PO Box 294 INJURY REPORTING TELEPHONES:
WEST PERTH WA 6872 (08) 9327 8800

Phone: (08) 9327 8777 Fax: (08) 9321 8973 1800 198118

Section 1: Employer Details

Employer Name:

Date of Injury:

Workplace Name:

Address:

_ _ / _ _ / _ _

Suburb/Town:

Postcode:

Phone Number:

Time of injury:

Fax Number:

_ _ : _ _ am

WorkCover Number:

_ _ : _ _ pm

Address of workplace

where injury occurred:

Suburb/Town:

Postcode:

Phone Number:

Fax Number:

Type of workplace

where injury occurred:

(eg. construction site, panel
beating shop, etc)

Section 2: Details of injured person

Surname:

Estimated time

Given Names:

person is unable to

Occupation:

work: _ _ _ days

Date of Birth: _ _ / _ _ / _ _ Age: _ _ _

Sex: Male: □ Female: □

Section 3: Injury Details

Nature of injury:

Brief description of how injury occurred:

Place injured person removed to:

Name of person reporting accident:

Position:

Phone Number:

Person for liaison:

Phone Number:

OFFICE USE ONLY:
□ Nat.
Person receiving report: . . . . . . . . . . . . . . . . . . . . . . . □ Loc.
□ Ag.
Date: _ _ / _ _ / _ _ Time: . . . . . . . . . . . . □ Type

[Form 1 amended in Gazette 7 Jun 2002 p. 2735‑6.]

Form 2 — Notification of Disease

[Regulation 2.5(2)]

Occupational Safety and Health Act 1984

WorkSafe Western Australia Commissioner
PO Box 294 DISEASE REPORTING TELEPHONES:
WEST PERTH WA 6872 (08) 9327 8800
Phone: (08) 9327 8777 Fax: (08) 9321 8973 1800 198118

Section 1: Employer Details

Employer Name:

Workplace Name:

Address:

Suburb/Town:

Postcode:

Phone Number:

WorkCover Number:

Fax Number:

Section 2: Details of person affected

Surname:

Given Names:

Occupation:

Date of Birth: _ _ / _ _ / _ _ Age: _ _ _

Sex: Male: □ Female: □

Section 3: Diagnosis Details

Name of Disease:

Date of Diagnosis:

Name of Medical Practitioner:

Address:

Suburb/Town:

Postcode:

Phone Number:

Fax Number:

Section 4: Description of work done by affected person.

Section 5:

Name of person reporting disease:

Position:

Phone Number:

Person for liaison:

Phone Number:

[Form 2 amended in Gazette 7 Jun 2002 p. 2736.]

[Form 3 deleted in Gazette 6 Jan 2006 p. 12.]

Form 4 — Reference of improvement notice for review

[Regulation 2.8(1)]

Occupational Safety and Health Act 1984 section 51

WorkSafe Western Australia Commissioner
PO Box 294
WEST PERTH WA 6872
Phone: (08) 9327 8777
Fax: (08) 9321 8973

Take notice that I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(print name of person referring notice for review)

refer improvement notice number □ □ □ □ □ □

issued by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(inspector)

on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . to you for review.
(date notice was issued)

The improvement notice relates to the workplace at:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(address)

of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(employer)

The notice is to be complied with before . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(compliance date on improvement notice)

I request the review on the following grounds:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Signature of person referring notice for review:

Date:

NOTE: A reference of an improvement notice for review must be made to the Commissioner within the time specified in the notice as the time before which the notice is required to be complied with [section 51(2)(a) of the Act].

[Form 4 amended in Gazette 7 Jun 2002 p. 2736.]

Form 5 — Reference of prohibition notice for review

[Regulation 2.8(2)]

Occupational Safety and Health Act 1984 section 51

WorkSafe Western Australia Commissioner
PO Box 294
WEST PERTH WA 6872
Phone: (08) 9327 8777
Fax: (08) 9321 8973

Take notice that I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(print name of person referring notice for review)

refer prohibition notice number □ □ □ □ □ □

issued by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(inspector)

on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . to you for review.
(date notice was issued)

The prohibition notice relates to the workplace at:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(address)

of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(employer)

Activity prohibited: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I request the review on the following grounds:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Signature of person referring notice for review:

Date:

NOTE: A reference of a prohibition notice for review must be made to the Commissioner within 7 days of the issue of the notice or such further time as may be allowed by the Commissioner [section 51(2)(b) of the Act].

[Form 5 amended in Gazette 7 Jun 2002 p. 2736.]

[Form 6 deleted in Gazette 9 Jul 2010 p. 3247.]

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Employer Name:		Date of Injury:
Workplace Name:
Address:		_ _ / _ _ / _ _

	Suburb/Town:
	Postcode:
	Phone Number:	Time of injury:
	Fax Number:	_ _ : _ _ am
	WorkCover Number:	_ _ : _ _ pm

Address of workplace
where injury occurred:
	Suburb/Town:	Postcode:
Phone Number:
Fax Number:
Type of workplace
where injury occurred:

Surname:		Estimated time
Given Names:		person is unable to
Occupation:		work: _ _ _ days
	Date of Birth: _ _ / _ _ / _ _ Age: _ _ _
	Sex: Male: □ Female: □

Nature of injury:
Brief description of how injury occurred:



Place injured person removed to:

Name of person reporting accident:
Position:
Phone Number:

Person for liaison:
Phone Number:

Name of Disease:
Date of Diagnosis:
Name of Medical Practitioner:
Address:

	Suburb/Town:	Postcode:
Phone Number:
Fax Number:

Name of person reporting disease:
Position:
Phone Number:

Person for liaison:
Phone Number: