Approved Form — AF2018-6 under s277 of the Work Health and Safety Act 2011 for the purpose of providing notice of entry by a permit holder under s117, s120 and s121.
Full name of WHS entry permit holder:		
Name of union represented:		
Provision in union’s rules that entitles the union to represent the industrial interests of a worker:		
Name and address of workplace being entered:		
Date of entry or proposed entry*:
*For entry under section 120 or 121: this notice must be given during usual working hours at least 24 hours, but not more than 14 days, before the entry	
	
Tick all of the check boxes relating to your reason/s for seeking entry below.  Details must also be provided where indicated.
•	Section 117 — entry to inquire into a suspected contravention of the WHS Act
Details of the suspected contravention to which this notice relates (what are the concerns, how do they contravene the WHS Act, what area of the workplace is affected): (attach separate pages if necessary)
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•	The above union is entitled to represent the industrial interests of a relevant worker who carries out work at this workplace. The relevant worker is a member, or eligible to be a member, of the above union.
•	The suspected contravention(s) of the WHS Act relates to, or affects, a relevant worker.
•	I reasonably suspect that a contravention(s) of the WHS Act has occurred or is occurring.	

•	Section 120 — entry to inspect employee records or information held by another person
Details of the suspected contravention to which this notice relates (what are the concerns, how do they contravene the WHS Act, what area of the workplace is affected): (attach separate pages if necessary) 
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Description of the employee records and other documents (or the class of records or documents) directly relevant to the suspected contravention, that are proposed to be inspected: (attach separate pages if necessary)
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•	The above union is entitled to represent the industrial interests of a relevant worker who carries out work at this workplace. The relevant worker is a member, or eligible to be a member, of the above union.
•	The suspected contravention(s) of the WHS Act relates to, or affects, a relevant worker.
•	I reasonably suspect that a contravention(s) of the WHS Act has occurred or is occurring.	

•	Section 121 – entry to consult and advise relevant workers on health and safety matters 
•	The above union is entitled to represent the industrial interests of a relevant worker who carries out work at this workplace. The relevant worker is a member, or eligible to be a member, of the above union.	

I reasonably believe and declare that the information in this form is true.
Signed:
Work Health and Safety Entry Permit Holder                                                                                         Date:	
NOTE: the legislation provides for civil penalties of up to $10,000 for individuals and $50,000 for a body corporate relating to breaches of right of entry laws.