WORKSAFE VICTORIA
REPORTING EMPLOYER ISSUES
June 2016
This form allows you to provide information to WorkSafe Victoria (WorkSafe)
about an employer you think may not have complied with their obligations
under the Workplace Injury Rehabilitation and Compensation Act 2013
(WIRC Act). If you are unsure about the response to a question or do not
know the information being asked, please leave the box blank.
WorkSafe will assess the information provided and take appropriate action.
Lodging the completed form
Email this form, along with any accompanying documents to:
enforcement_compensation@worksafe.vic.gov.au
Or via post to:
Compensation Investigations Team
Enforcement Group
GPO Box 4306 Melbourne 3001
YOUR DETAILS
Full Name
Telephone Number Mobile Number
Email Address
Are you an injured worker?
Yes No
If not, please describe your relationship to the injured worker
below (e.g. friend, spouse, lawyer)
If you are not an injured worker, please record the injured worker's
details below:
INJURED WORKER INFORMATION
Full Name
Telephone Number Mobile Number
Date of Birth
Address
Claim number
INJURY EMPLOYER INFORMATION
Employer Name
Employer Address
Type of business
YOUR COMPLAINT
Does your complaint relate to a current claim for compensation?
Yes No Unsure
What obligations under the WIRC Act do you believe have not been
met by the employer? (please check the relevant boxes)
Failure to forward a claim for compensation
Late payments
Failure to provide suitable duties
Failure to plan return to work
Discriminatory conduct following an injury or claim lodgement
Other (please record below)
Are you willing to provide a signed statement regarding your
complaint which may be used in proceedings before a Court?
Yes No Unsure
COMPLAINT SUMMARY
Please describe the main issues relating to your complaint by
providing as much information as possible below
WorkSafe Victoria is a trading name of the Victorian WorkCover Authority
FOR870/01/06.16 Page 1 of 1
FOR870.indd 1 15/07/2016 1:45 PM
