Form A50
APPLICATION FOR REVIEWABLE DECISION
(WORK HEALTH AND SAFETY)
Case Number
(SAET use only)
About this form

This is an application to SAET in respect of certain action under the Work Health and Safety Act 2012 (SA).

A copy of this application is to be provided by the applicant to the other parties considered to have a direct
interest in the matter (or their representatives) as nominated within this form.

Submitting an incomplete form (including any relevant supporting documents) may result in delays.
THE APPLICATION
The applicant applies to SAET pursuant to the Work Health and Safety Act 2012 seeking SAET to:
☐ An order in relation to discriminatory or coercive conduct. (section 112)
☐ An injunction for noncompliance with an improvement notice, prohibition notice or non-disturbance
notice. (section 215)
☐ Proceedings for contravention of a WHS civil penalty provision. (section 255)
☐ Other (specify legislative provision and nature of the application)
PARTY DETAILS
Applicant
☐ the Regulator
The applicant is:
☐ an employer
☐ a health and safety representative
☐ a deputy health and safety representative
☐ Other - (specify):
Organisation name (if
relevant)
☐ Mr
Title
First name
☐ Mrs
☐ Miss
☐ Ms
☐ Other (specify):
Last name
Email
Telephone
Address
Mobile
Street 1
Street 2
Suburb
State
Postcode
Is anyone representing
you?
www.saet.sa.gov.au
SAET Registry: 08 8207 0999
Country
☐ No
☐ Yes. Please specify:
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South Australian Employment Tribunal
Form A50 – Application for reviewable decision (Work Health and Safety)
Representative detail (if required)
Organisation
Contact First name
Last name
Email
Telephone
Address
Mobile
Street 1
Street 2
Suburb
State
Postcode
Country
Other party 1 - provide details of other parties that have a direct interest in the matter
☐ Mr
Title
☐ Mrs
☐ Miss
First name
☐ Ms
☐ Other (specify):
Last name
Email
Telephone
Address
Mobile
Street 1
Street 2
Suburb
State
Postcode
Is anyone representing
you?
Country
☐ No
☐ Yes. Please specify:
Representative detail (if required)
Organisation
Contact First name
Last name
Email
Telephone
Address
Mobile
Street 1
Street 2
Suburb
State
Postcode
Country
Other party 2 - provide details of other parties that have a direct interest in the matter
Title
First name
☐ Mr
☐ Mrs
☐ Miss
☐ Ms
☐ Other (specify):
Last name
Email
www.saet.sa.gov.au
SAET Registry: 08 8207 0999
Version as at 1 July 2017
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South Australian Employment Tribunal
Form A50 – Application for reviewable decision (Work Health and Safety)
Telephone
Address
Mobile
Street 1
Street 2
Suburb
State
Postcode
Is anyone representing
you?
Country
☐ No
☐ Yes. Please specify:
Representative detail (if required)
Organisation
Contact First name
Last name
Email
Telephone
Address
Mobile
Street 1
Street 2
Suburb
State
Postcode
Country
Other party 3 - provide details of other parties that have a direct interest in the matter
☐ Mr
Title
☐ Mrs
First name
☐ Miss
☐ Ms
☐ Other (specify):
Last name
Email
Telephone
Address
Mobile
Street 1
Street 2
Suburb
State
Postcode
Is anyone representing
you?
Country
☐ No
☐ Yes. Please specify:
Representative detail (if required)
Organisation
Contact First name
Last name
Email
Telephone
Address
Mobile
Street 1
Street 2
www.saet.sa.gov.au
SAET Registry: 08 8207 0999
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South Australian Employment Tribunal
Form A50 – Application for reviewable decision (Work Health and Safety)
Suburb
State
Postcode
Country
SPECIAL REQUIREMENTS
Does any party require an
interpreter?
☐ No
☐ Yes. Please specify language:
Does any party have any
special requirements
which will require
assistance?
☐ No
☐ Yes. Please specify:
DETAILS OF APPLICATION
Orders sought
Describe the following in the space provided below:

The general circumstances in which the matter has arisen including the location of the workplace;

If applying under s.215, attach a copy of the improvement notice, prohibition notice or non-disturbance
notice;

The applicant’s claim in relation to the matter(s) in dispute;

The steps already taken to attempt to resolve the matter; and

Dates of notices and any contraventions etc alleged.
Attach additional pages if necessary.
www.saet.sa.gov.au
SAET Registry: 08 8207 0999
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South Australian Employment Tribunal
Form A50 – Application for reviewable decision (Work Health and Safety)
LODGING YOUR COMPLETED FORM
The person lodging this form must send a copy to all other party/ies.
Name of person lodging
Signature
Date
Please lodge this form, together with any accompanying documents, with the South Australian Employment
Tribunal:
Email: [email protected]
Post: PO Box 3636, Rundle Mall, SA, 5000
In person: Level 6, Riverside Centre, North Terrace, Adelaide, 5000
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR OWN RECORDS
www.saet.sa.gov.au
SAET Registry: 08 8207 0999
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