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ACCESS APPLICATION
GOVERNMENT INFORMATION (PUBLIC ACCESS) ACT 2009
Please complete this form to apply for formal access to government information held by SafeWork NSW 
under the Government Information (Public Access) Act 2009 (GIPA Act). If you need help with filling out 
this form, please contact SafeWork NSW’s Right to Information Officer or visit their website (see over 
for details).
Section 1. YoUR DetAiLS
Title Family/Surname
Other names
Given name
Name of party on whose behalf you are acting 
(if applicable)
CONTACT ADDRESS
Unit number/Street number/Property number 
(include Lot or DP number if applicable)
Daytime contact number 
Mobile number
Street name
Company
Suburb
Email
State  
Postcode
Email I agree to receive correspondence at the 
above email address.
Please select
Section 2. PRooF oF iDentitY
When seeking access to any person’s personal information (including your own), an applicant must provide 
proof of identify in the form of a certified* copy of any one of the following documents:
Mark one box only.
Australian driver’s licence (with photograph, signature and current address)
Current Australian passport
Other proof of signature and current address details
* Certified means that your proof of identify must be verified (such as – signed and dated) by an authorised 
person (Justice of the Peace, doctor, teacher, pharmacist, legal practitioner, Postmaster – Australia Post).
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ACCESS APPLICATION GOVERNMENT INFORMATION (PUBLIC ACCESS) ACT 2009 DECEMBER 2018
Section 3. GoVeRnMent inFoRMAtion
Please describe in detail the information you would like to access to allow the record(s) to be identified. 
(Note: If you do not give enough details about the information, the agency may refuse to process your application).
Other information you can provide that may assist in the identification of relevant documents.
If you are requesting information about a SafeWork NSW investigation or a workplace incident, SafeWork 
NSW requires some additional details with your application. The following details are required:
Name of the injured worker
Date the incident occurred (DD/MM/YYYY)
Name of the employer
ADDRESS OF WORKPLACE OR SITE WHERE INCIDENT OCCURRED
Unit number/Street number/Property number 
 
(include Lot or DP number if applicable)
Suburb
Street name
State  
Postcode
Please select
Primary activity undertaken at workplace where incident occurred (such as – construction)
SafeWork NSW file reference or name of SafeWork NSW inspector (if known)
Description of documents you would like to access (if known)
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ACCESS APPLICATION GOVERNMENT INFORMATION (PUBLIC ACCESS) ACT 2009 DECEMBER 2018
Section 4. FeeS AnD cHARGeS
Application fee – A fee of $30 applies to all access applications.
Processing cannot proceed until this fee is paid. Please see the application fee payment section on the 
following page.
ADDITIONAL PROCESSING CHARGES
The application fee for applicants seeking access to their own personal information provides for 20 hours 
of processing time. A charge of $30 (or $15 concession*) per hour is applied thereafter.
The application fee for applicants seeking access to non-personal information provides for one hour of 
processing time. A charge of $30 (or $15 concession*) per hour is applied thereafter.
*A $15 concession applies for fees and processing charges where an applicant can certify the following:
•  the applicant holds a Pensioner card or a Health Benefit card, or
•  is a full time student, or
•  represents a non-profit organisation, or
•  is able to demonstrate financial hardship.
Section 5. DiScLoSURe LoG
If the information you have requested is released to you and would be of interest to other members of the 
public, details about your application may be recorded in the agency’s ‘disclosure log’. This is published on 
the agency’s website.
Do you object to this?
Yes
No
Applicant’s signature
Date (DD/MM/YYYY)
Section 6. FoRM oF AcceSS
How do you wish to access the information?
A copy of the documents
Access in another way (please specify below)
Section 7. conSULtAtion
Information/records that relate to other persons or businesses may require third party consultation before 
a decision to release them can be made. Your response to the following questions will be taken into 
consideration in these instances.
Do you understand that other involved persons may be contacted to obtain their consent to release 
information/records to you?
Yes
No
Do you understand that to undertake third party consultation, the time taken to respond to your 
application will be extended by a further 10 working days?
Yes
No
Do you consent to the other party being given your details as the applicant requesting their information?
Yes
No
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ACCESS APPLICATION GOVERNMENT INFORMATION (PUBLIC ACCESS) ACT 2009 DECEMBER 2018
Section 8. PRiVAcY StAteMent
SafeWork NSW respects your privacy and is committed to protecting your personal information. We 
operate in accordance with the provisions of the Privacy and Personal Information Protection Act 1998.
The purpose of collecting the information requested is to allow SafeWork NSW to process your access 
application under the Government Information (Public Access) Act 2009. The information will be reviewed 
and held by the Right to Information team, it will not be shared with any third parties. Please note all 
information provided will be treated confidential.
Section 9. APPLicAtion LoDGeMent
Please address completed forms to the Right to Information Team at SafeWork NSW.
Postal Address:  SafeWork NSW 
Email Address: xxxx@xxxxxxxx.xxx.xxx.xx
Locked Bag 2906 
Phone: (02) 4321 5000
Lisarow NSW 2252
Toll Free: 13 10 50
Website: www.safework.nsw.gov.au
Section 10. APPLicAtion Fee PAYMent
The $30 application fee must be paid when this notification is submitted.
Pay by cheque. Enclose a cheque made payable to SafeWork NSW.
Pay by money order. Enclose a money order made payable to SafeWork NSW.
Pay by credit card.  Please charge $30.00 to my: 
MasterCard
Visa
A payment processing fee applies to credit card payments (MasterCard and Visa 0.40%) plus applicable GST.
Card number
Card expiry date (MM/YYYY)
Cardholder name (please print name as displayed on credit card)
Cardholder signature
Date (DD/MM/YYYY)
FURtHeR inFoRMAtion
You can contact the Information and Privacy Commissioner NSW for further information on the GIPA Act 
at www.ipc.nsw.gov.au or by telephone on 1800 472 679.
Catalogue No. SW08068
© Copyright SafeWork NSW 1218
Locked Bag 2906, Lisarow, NSW 2252 | Customer Experience 13 10 50 
SafeWork NSW, 92–100 Donnison Street, Gosford, NSW 2250 
Website www.safework.nsw.gov.au
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