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NOTIFICATION OF INTEREST
IN KNOWING ENFORCEMENT
ACTION
This notification is made under section 142 of the Health and Safety
at Work Act 2015
Your details
Name:
(first name, last name)
Postal address:
Town/city: Postcode:
Phone number: Mobile number:
Email:
Description of matter of interest
Provide the address or location of the place of work where the matter occurred or is occurring:
Date(s)*:
Time(s)*:
*See below for notes about completing the date and time section of this form
Provide details about the incident, situation, or set of circumstances that constituted or constitute the matter:
Declaration
I declare that to the best of my knowledge, the information provided in this notification is true and correct.
Name:
Note: the above declaration is considered to be an electronic signature that is reliable as appropriate for the purpose of this notification
Date:
Notes about completing this form:
a. If the matter arose from a single incident, the date and time of the matter
b. If the matter is a repeated matter, the dates and times for each occurrence of the matter
c. If the matter is a continuing matter, the date and time when the matter commenced
d. If the matter has ceased, the date and time when the matter ceased.
e. If the time and/or date is unknown, note this in the time and date sections.
Notes to users:
This notice meets the requirements for notification of interest in the manner prescribed by the regulations,
but alternative means of notification may be used if consistent with the regulations themselves.
See the reverse of this page for information on how to submit this form.
