Application Form BIG OHS Essentials Program Application Form BIG OHS Essentials Program Business DetailsABN * (Enter your 11 digit ABN without spaces or special characters)*Business / Company Name*Number/Street * (Not PO Box)*State*— Please Select —VICNSWSACity/Suburb*Postcode*Contact DetailsName* First Last Work phone * (including area code without spaces)*Mobile*Email* Number of work sitesNumber of full-time employees*Number of part-time or casual employeesIndustry*— Please Select —AGRICULTURE, FORESTRY & FISHMININGMANUFACTURINGELECTRICITY, GAS, WATER, WASTECONSTRUCTIONWHOLESALE TRADERETAIL TRADEACCOMMODATION & FOOD SERVICESTRANSPORT, POSTAL &WAREHOUSINGINFORMATION MEDIA & TELECOMMSFINANCIAL & INSURANCE SERVICESRENTAL, HIRING & REAL ESTATEPROF, SCIENTIFIC & TECH SVCSADMINISTRATIVE & SUPPORT SVCSPUBLIC ADMINISTRATION & SAFETYEDUCATION AND TRAININGHEALTHCARE & SOCIAL ASSISTANCEARTS AND RECREATION SERVICESOTHER SERVICESNature of your business*The predominant activity undertaken at the workplace e.g. manufacturing and assembly of industrial boilers.Have you previously had a safety consultant visit as part of this program?*YesNoDo you have WorkCover Insurance?*YesNoYour WorkCover Insurance provides insurance cover provides insurance cover for the costs of benefits if your workers are injured or become ill because of their work. It is compulsory for most Victorian employers to take out WorkCover insurance.Are you a member of any of the following associations? Housing Industry Association Victorian Automobile Chamber of Commerce Master Builders Association of Victoria Landscape Victoria (Landscape Industry Association of Victoria Australian Industry Group National Electrical and Communications Association Civil Contractors Federation Victorian Employers Chamber of Commerce and Industry Victorian Farmers Federation Where do you currently go to find out about OHS?— Please Select —WSV WebsiteWSC InspectorWSV Seminar / EventOHS ConsultantSmall Business VictoriaIndustry AssociationUnionOtherOtherWhere did you hear about this program?*— Please Select —WSV WebsiteWSV InspectorWSV Seminar / EventOHS ConsultantSmall Business VictoriaIndustry AssociationUnionOtherOtherWhat are the main OHS issues you would like help with (Select up to 5)* Manual handling including lifting, twisting, pulling, pushing. Dangerous goods and hazardous substances including chemicals, gas, petrol, asbestos and explosives. Plant and equipment safety including machinery, guarding, tools and forklifts. Slips, trips and falls. Construction and related activities including working from heights, scaffolding, confined spaces, and trenches. Work station setup including computer. Documentation and policies including risk assessment, safe work method statements, job safety analysis and consultation. Register of injuries and return to work. Other
