The Next Steps

Application for Healthier Work Recognition – following year (gold)
Business Name: / Number of staff (FTE):
ABN: / Industry:
Physical address:
Postal address:
HW Champion:
Position: / Phone: / Email:
Checklist
Ensure you can answer ‘yes’ to ALL of the below questions to make sure we can process your application without delay. / Yes / No
Has your workplace had a visit from a Healthier Work Industry Advisor in the last 6 months?
Has the Healthier Work 12 Month Plan template been completed, and attached to this application?
Has one health priority area been chosen for each season in the 12 Month Plan (with at least 3 health priority areas chosen over 12 months)?
Has one ‘people’ strategy chosen for each season in the 12 Month Plan?
Has one ‘place’ strategy chosen for each season in the 12 Month Plan?
Will all activities in the 12 Month Plan take place in the ACT?
Has the CEO (or equivalent) approved the 12 Month Plan?
Has the ‘what we learnt’ form been completed, and attached to this application?
Has the online “Health Score Card” been completed?
Can you confirm that the organisation named on this application has not been issued with any infringement or prohibition notices under the Workplace Health and Safety Act 2011(ACT)in the last three years?
Can you confirm that the organisation named on this application has not been issued with any infringement or recovery of premium avoidance action in the last three years under the Workers Compensation Act 1951?
I agree to inform Healthier Work within seven days if the business name associated with the Recognition Scheme becomes the subject of investigation in respect of a breach of the Workplace Health and Safety Act 2011 (ACT) or the Workers Compensation Act 1951.
Has the workplace consulted with staff on the development of the 12 month plan?
How were staff consulted in the development of the 12 month plan?
Important Information
Applicants must ensure all relevant insurance, including workers’ compensation and public liability insurance, is obtained in relation to the 12 month plan for the Recognition Scheme. If requested by Healthier Work, applicants must provide evidence of the certificate of currency for those insurance policies.
Healthier Work reserves the right to decline or to disqualify, an application at its absolute discretion, including but not limited to situations in which the applicant, or a related person or organisation, has breached or is under investigation for possible breaches of occupational health and safety laws (whether or not a prosecution is pending), or where the acceptance of the application may otherwise be detrimental to the objectives of Healthier Work.

The next steps

Submit this application form, the ‘what we learnt’ evaluation and your completed 12 Month Plan, including the outline and steps your workplace will take to implement the plan, to:

Post: OrEmail:

Healthier Work
WorkSafe ACT

GPO Box 158
Canberra City ACT 2601

Healthier Work will receipt the arrival of your documents within three working days of receiving it.

Healthier Work will review your documentation to ensure it satisfies the requirements outlined in the Healthier Work Recognition Scheme Guidelines (if you need a copy of the Guidelines, let us know).
If your 12 month plan is not accepted we will contact you and offer further assistance so you can re-submit an application.

Healthier Work will inform you once we have approved your application for the Recognition Scheme. At this time we will also arrange an appointment with the CEO (or equivalent) and Healthier Work Champion to present the Recognition Certificate, take a photo and have the 12 month plan signed off by the CEO.

Signature
I understand that by reading this completed application form and signing it, I am authorising my business to be considered for Recognition as part of the Healthier Work Recognition Scheme.
I will inform Healthier Work if I do not agree to them providing the information contained within this application to the evaluation team employed by the Health Directorate, ACT Government, to support the improved outcomes of the program. The evaluation team may contact my organisation to discuss the Recognition Scheme. The evaluation team will not disclose any data attributable to an organisation without prior consent of the organisation.
I understand that if accepted for the Healthier Work Recognition Scheme, my business name and photos may be used for promotional purposes through social media, the Healthier Work website, The Canberra Times and other promotional opportunities as they arise.
Name of CEO (or equivalent):
Signature:
Date: