Forms

Form 44 - Provisional Improvement Notice (PINs)

Provisional Improvement Notice (PIN) form used at the workplace by the Workplace Health and Safety Representative.

Form 3 - Incident notification form

Incident notification (Form 3). Use this form (or the online service) to notify of a serious injury, electrical incident, serious illness, fatality, or dangerous incident at your workplace.

Suitable duties program

For employers to complete. This two-page template creates a four week return to work plan.

FM106 Claim Form

Use this form to make a claim with WorkCover Queensland or your self-insurer for a work-related illness or injury.

Health and safety checklist for working from home

Checklist to assess WHS risks for working from home arrangements.

Healthy worker funding program application form

Application form for high-risk industries for work health funding program

Worker determination form

This form is for use by policy holder/employer.

EFT Payment Form FM204

Complete this form to get paid (electronic funds transfer).

Request for surgery FM302

Request for surgery approval - This form is only to be used for claims where WorkCover Queensland is the insurer.

Form 28 - Hazardous chemicals health monitoring report

Under the Work Health and Safety Regulation 2011 where health monitoring is required for a hazardous chemical, the PCBU must send a copy of the health monitoring report to Workplace Health and Safety Queensland in certain circumstances.

Be recognised - Assessment for silver recognition

Be recognised silver application form to be recognised for health and wellbeing at work.

Statutory appointments and public sector employment currently held

We ask candidates for appointment to a government body to complete and sign this form. It tells us about your current public sector employment and any statutory appointments to Qld Government bodies and the amount of remuneration (including daily meeting fees) received for them.The Department of Education is collecting your personal information for the purpose of assessing your eligibility for appointment to Queensland Government statutory bodies and to receive fees should you be appointed.