Form 71 - Request For Regulator To Commence A Prosecution
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1FORM 71
V28.2.12
ABN 13 846 673 994
Request for regulator to commence a prosecution
Work Health and Safety Act 2011
Request made under section 231 of the Work Health and Safety Act 2011 to the regulator that a prosecution be brought.
Requestor’s details:
Full name:
Mr / Mrs / Miss / Ms
First name
Surname
Email address:
Contact number:
Postal address:
Postcode:
Do you consent to the regulator making the parties aware that the
Yes
No
issue has been raised by you?
What is your relationship with the workplace to which your issue relates?
Nature of the work health and safety issue:
Description of the issue (nature of risk, perceived contravention of law):
Date the offence occurred:
/
/
Time the offence occurred:
:
)
(24 hr time
Details of the person conducting the business or undertaking you believe has committed
the offence:
Name of business:
Business address:
ABN:
ACN:
(if known)
(if known)
Business contact number:
Mobile number:
Business email address:
People who may have information relevant to the alleged offence:
Name
Position
Contact details
Please submit this request to the regulator in writing via email, fax or post to:
The regulator, Workplace Health and Safety Queensland Advisory and Assessment Centre, PO Box 820, Lutwyche Qld 4030
Email: whsqaaa@justice.qld.gov.au Fax: (07) 3247 0297
Note:
1. The regulator will maintain confidentiality over your personal details to the extent permissible and required by law.
2. It may be necessary for the regulator to formally take a statement from you concerning your request.
3. You are advised that it is a requirement of the Work Health Safety Act 2011 that as a result of your request to the regulator to commence
a prosecution, the person you believe committed the offence will be informed by the regulator of the request and of regulator’s decision.
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