Small Business Application


Small Business Safety Assistance Application
* mandatory field
ABN
*Business/Company Name
*Address of Workplace (not PO Box)	Street Suburb Postcode
*Contact Person
*Phone
Mobile
Email
Nature of Business/Industry Sector
*Number of Employees	Full Time Part Time
Is your business covered by WorkSafe Injury Insurance	Yes No
Instructions (Select those issues relevant to your business)	Manual Handling (Lifting/twisting/pulling/pushing tasks) Chemicals including safe use/storage and material safety data sheets Working at Heights/including ladders/scaffolding/harnesses Plant Safety including machinery/tools/guarding etc Air Quality & Ventilation re glues/petrol/chemicals Importers/Suppliers/Manufacturers Duties Pallet Racking/order picking/order packing Forklifts/including traffic management plan Contractors Consultation Licensing Slips/Trips/Falls Electrical Safety Demolition Dangerous Goods including gas/petrol/oils/explosives Infection (animals/humans/waste) Occupational Violence from customers/patients/visitors or Bullying in the workplace etc Trenching Welding/Cutting Job Safety Analysis/Safe Work Method Statement/ Health and Safety Co-ordination Plan Policy/Procedures Heat Asbestos or Lead Confined Spaces Tractor/ATVs Cranes and Hoists Fatigue or Stress Noise Emergency response including first aid/fire/explosion/robbery Register of injuries or Return to Work Safety Induction Computer Workstation Setup
Have you received a notice from an Inspector ?	Yes No
If yes what is the expiry date (dd/mm/yyyy)?	/ /
List any other issues you would like addressed
WorkSafe Victoria OHS Newsletter	Would you like to receive an email newsletter from WorkSafe Victoria on OHS for : Construction ? Yes No Manufacturing, Logistics & Agriculture ? Yes No

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