Right to Information and Information Privacy
Internal review application form

Use this form to request an internal review of a decision that has been made on your application either under the Right to Information Act 2009 (RTI) or Information Privacy Act 2009 (IP).

Your application must be received within 20 business days after the date of the written notice of decision.

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FM213

Right to Information and Information Privacy
Internal review application form

Submit this form

By email to

By fax to 1300 651 387

By post to GPO Box 2459, Brisbane Qld 4001

We have 20 business days from the date we receive your application to notify of our decision.

For more information, visit our website at www.workcoverqld.com.au or call us on 1300 362 128.

Part 1—applicant details

Surname or family name of applicant

Given names of applicant Title

(If you are an agent, please attach a copy of the authority to release
information to you)

Company name

Position

Postal address

Number and street
Suburb/town / Postcode

Contact details

Home telephone / Work telephone
Mobile number
Email address

Please tell us if you are:

the original applicant

a consulted third party

Part 2—review details

RTI reference number (if known)

Date of decision letter

Person who made decision

Please tell us what decision you would like reviewed:

access to a document has been refused (in part of full)

access to a document has been deferred

access to a document was given in a form other than requested

amendment to a document has been refused

an application fee has been incorrectly charged

a processing or access charge has been incorrectly charged

Please specify your reasons for requesting a review:

Part 3—declaration

Privacy notice

WorkCover Queensland is collecting your personal information to process your application. WorkCover Queensland undertakes all reasonable measures to protect your privacy by collecting, using, storing, and disclosing the personal information we hold about you in accordance with the Information Privacy Act 2009.

Your information will be accessed by persons authorised to do so and will not be given to any other person unless you have given your consent, or we are authorised or required by law.

For more information on privacy, visit our website at www.workcoverqld.com.au or call us on 1300 362 128.

Applicant’s statement

I declare that:

  1. The information provided on this form is complete and correct.
  2. I have read the privacy notice.
  3. I have attached any supporting documentation, including any evidence of identity or authority.

Full name
Date// / I agree

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