South Australian Employment Tribunal

Form A50 – Application for reviewable decision (Work Health and Safety)

Form A50

Application for reviewable decision (Work Health and Safety)

Case Number
(SAET use only)

About this form

  • This is an application toSAETin respect of certain action under the Work Health and Safety Act 2012 (SA).
  • A copy of this application is to be provided by the applicant to the other parties considered to have a direct interest in the matter (or their representatives) as nominated within this form.
  • Submitting an incomplete form (including any relevant supporting documents) may result in delays.

The Application

The applicant applies to SAET pursuant to the Work Health and Safety Act 2012 seeking SAET to:

☐ An order in relation to discriminatory or coercive conduct. (section 112)

☐ An injunction for noncompliance with an improvement notice, prohibition notice or non-disturbance notice. (section 215)

☐ Proceedings for contravention of a WHS civil penalty provision. (section 255)

☐ Other (specify legislative provision and nature of the application)

Party details

Applicant

The applicant is: / ☐ the Regulator ☐ an employer ☐ a health and safety representative
☐ a deputy health and safety representative ☐ Other - (specify):
Organisation name (if relevant)
Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
Is anyone representing you? / ☐ No ☐ Yes. Please specify:

Representative detail (if required)

Organisation
Contact First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

Other party 1 - provide details of other parties that have a direct interest in the matter

Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
Is anyone representing you? / ☐ No ☐ Yes. Please specify:

Representative detail (if required)

Organisation
Contact First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

Other party 2 - provide details of other parties that have a direct interest in the matter

Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
Is anyone representing you? / ☐ No ☐ Yes. Please specify:

Representative detail (if required)

Organisation
Contact First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

Other party 3 - provide details of other parties that have a direct interest in the matter

Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
Is anyone representing you? / ☐ No ☐ Yes. Please specify:

Representative detail (if required)

Organisation
Contact First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

Special requirements

Does any party require an interpreter? / ☐ No ☐ Yes. Please specify language:
Does any party have any special requirements which will require assistance? / ☐ No ☐ Yes. Please specify:

Details of application

Orders sought

Describe the following in the space provided below:

  • The general circumstances in which the matter has arisen including the location of the workplace;
  • If applying under s.215, attach a copy of the improvement notice, prohibition notice or non-disturbance notice;
  • The applicant’s claim in relation to the matter(s) in dispute;
  • The steps already taken to attempt to resolve the matter; and
  • Dates of notices and any contraventions etc alleged.

Attach additional pages if necessary.

LODGING YOUR COMPLETED FORM

The person lodging this form must send a copy to all other party/ies.

Name of person lodging
Signature
Date

Please lodge this form, together with any accompanying documents, with the South Australian Employment Tribunal:

Email:
Post: PO Box 3636, Rundle Mall, SA, 5000
In person: Level 6, Riverside Centre, North Terrace, Adelaide, 5000

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR OWN RECORDS

SAET Registry: 08 8207 0999