Provisional Improvement Notice Form

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PROVISIONAL IMPROVEMENT NOTICE
Work Health and Safety Act 2011
This Provisional Improvement Notice (PIN) is issued under section 90 of the Work Health and Safety Act 2011 (the WHS Act).
This PIN requires the duty holder to whom it is issued to remedy a contravention, prevent a likely contravention from occurring, or
remedy the things or operations causing the contravention or likely contravention of the WHS Act or Regulation. Depending on
the particular contravention, the duty holder may be an individual natural person or an organisation such as a company or public
authority. Section 97 requires that the person to whom a PIN is issued must, as soon as possible, display a copy of the PIN in a
prominent place at or near the workplace, or part of the workplace at which work is being carried out that is affected by the PIN.
There are a number of things that must be done or taken into account before a PIN is issued by a HSR – see reverse side of
this form for relevant information.
1:
Health and Safety Representative (HSR)
Given Names:
Surname:
Contact number:
Name of Work Group:
2:
PIN issued to
Name of duty holder:
Address:
Postcode:
3:
PIN given to (If the PIN is given to someone on behalf of the duty holder)
Given Name:
Surname:
Position:
4:
Details of contravention
Site location:___________________________________________________________________________________________________________
I, _________________________________________ reasonably believe on ______________________________ at _______________________
insert Health and Safety Representatives name
insert date
insert time
that you
are contravening a provision or
have contravened a provision in circumstances that make it likely that the
contravention will continue or be repeated of the:
Work Health and Safety Act 2011, section ________________
Work Health and Safety Regulation 2011, regulation ______________
Brief description of how the provision is being or has been contravened:
(Optional) In accordance with section 93
the
(1) of the Work Health and Safety Act 2011,
remedial and/or preventative
measures I believe should be taken to deal with the contraventions, likely contraventions or existing causes thereof:
.
5:
Compliance
Date PIN issued
Date compliance with PIN required
Signature of HSR
/
/
/
/
20
20
(Min. 8 days after date PIN issued)

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