Regulation 5.30 of the Occupational Safety and Health Regulations 1996
Organisation’s details
Organisation (Employer) Name:
Organisation Address:
Address where carcinogen to be used:
Proposed carcinogen use
Nature of carcinogen use:
Reason a safer chemical could not be used:
Method of carcinogen use
(attach further information/procedure if needed)
Quantity per annum to be used: / Number of people who may be exposed:
Safety Measures
Risk assessment completed:
Name and position of person who did the risk assessment:
Application to Use a Scheduled Carcinogen
Safety Measures cont.
Safety equipment (e.g. ventilation/isolation equipment):
Scheduled maintenance program for safety equipment including ventilation (documented):
Restrictions of use and access:
Storage provisions:
Spill management equipment and procedure:
Waste management:
Personal protective equipment to be worn (specify):
Training provided to people who use or who could be exposed (keep records):
Written procedure for use includes safety risks and precautions:
Application to Use a Scheduled Carcinogen
Safety Measures cont.
First aid facilities:
Trained first aider:
Administrative Measures
Administrative procedures in the event of exposure, including company record of incident (keep 30 years), information to exposed person/s, health surveillance, notification to WorkSafe Commissioner.
Procedure to provide updated information to WorkSafe Commissioner when information provided in this application changes, the risk assessment is reviewed, or at least every 5 years:
Procedure to provide information to exposed employees on cessation of employment:
Investigation procedure – hazards/incidents
System to consult with employees on safety and health issues:
Declaration
Declaration of use:
(only if Schedule 5.4 or 5.6 carcinogen) / I, ______, declare that this chemical will only be used for analysis/bona fide research (strike out that which does not apply). Signature: ______Date: ______
Application to Use a Scheduled Carcinogen
Contact Details of Person Submitting Application (Applicant)
Applicant Name: / Applicant Signature:
Applicant Phone: / Application date:
Applicant Email:
Submit Application
To submit application: / Post to:
Director Health Hazards and Plant Safety
WorkSafe
Locked Bag 14
CLOISTERS SQUARE WA 6850
Enquiries about application: / Phone: (08) 6251 2311
Email:
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WorkSafe - Application to use scheduled carcinogen – v. 4 – 17/02/2015