Application for Healthier Work Recognition Scheme
Workplace Information
Business Name:
ABN:
Physical address:
Number of staff (FTE):
Industry: Choose an item.
Postal address:
HW Champion:
Position:
Phone:
Email:
Checklist
Ensure you can answer ‘yes’ to ALL of the below questions to make sure we
can process your application without delay.
Has your workplace had a visit from a Healthier Work Industry Advisor in the last
6 months?
Has the Healthier Work 12 Month Plan template been completed, and attached to
this application?
Has one health priority area been chosen for each season in the 12 Month Plan
(with at least 3 health priority areas chosen over 12 months)?
Have two ‘people’ strategies chosen for each season in the 12 Month Plan?
Has one ‘place’ strategy chosen for each season in the 12 Month Plan?
Will all activities in the 12 Month Plan take place in the ACT?
Has the CEO (or equivalent) approved the 12 Month Plan?
Has the Pre-Program Questionnaire form been completed, and attached to this
application?
Can you confirm that the organisation named on this application has not been
issued with any infringement or prohibition notices under the Workplace Health
and Safety Act 2011 (ACT) in the last three years?
Can you confirm that the organisation named on this application has not been
issued with any infringement or recovery of premium avoidance action in the last
three years under the Workers Compensation Act 1951?
I agree to inform Healthier Work within seven days if the business name associated
with the Recognition Scheme becomes the subject of investigation in respect of a
breach of the Workplace Health and Safety Act 2011 (ACT) or the Workers
Compensation Act 1951.
Has the workplace consulted with staff on the development of the 12 month plan?
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Yes
No
Application for Healthier Work Recognition Scheme
How were staff consulted in the development of the 12 month plan?
Important Information
Applicants must ensure all relevant insurance, including workers’ compensation and public liability insurance,
is obtained in relation to the 12 month plan for the Recognition Scheme. If requested by Healthier Work,
applicants must provide evidence of the certificate of currency for those insurance policies.
Healthier Work reserves the right to decline or to disqualify, an application at its absolute discretion, including
but not limited to situations in which the applicant, or a related person or organisation, has breached or is
under investigation for possible breaches of occupational health and safety laws (whether or not a prosecution
is pending), or where the acceptance of the application may otherwise be detrimental to the objectives of
Healthier Work.
The next steps

Submit this application form, the Pre-Program Questionnaire and your completed 12
Month Plan, including the outline and steps your workplace will take to implement the
plan, to:
Post:
Or
Healthier Work
WorkSafe ACT
GPO Box 158
Canberra City ACT 2601
Email:
[email protected]

Healthier Work will receipt the arrival of your documents within three working days of
receiving it.

Healthier Work will review your documentation to ensure it satisfies the requirements
outlined in the Healthier Work Recognition Scheme Guidelines.
o If your 12 month plan is not accepted we will contact you and offer further
assistance so you can re-submit an application.

Healthier Work will inform you once we have approved your application for the
Recognition Scheme. At this time we will also arrange an appointment with the CEO (or
2
equivalent) and Healthier Work Champion to present the Recognition Certificate, take a
photo and have the 12 month plan signed off by the CEO.
Signature
I understand that by reading this completed application form and signing it, I am authorising
my business to be considered for Recognition as part of the Healthier Work Recognition
Scheme.
I will inform Healthier Work if I do not agree to them providing the information contained
within this application to the evaluation team employed by the Health Directorate, ACT
Government, to support the improved outcomes of the program. The evaluation team may
contact my organisation to discuss the Recognition Scheme. The evaluation team will not
disclose any data attributable to an organisation without prior consent of the organisation.
I understand that if accepted for the Healthier Work Recognition Scheme, my business name
and photos may be used for promotional purposes through social media, the Healthier Work
website, The Canberra Times and other promotional opportunities as they arise.
Name of CEO (or equivalent):
Signature:
Date:
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