This Default Notice is issued in accordance with Section 35(3) of the South Australian Occupational Health,
Safety and Welfare Act 1986.
Failure to comply with its requirements carries a maximum penalty of $40 000.
being the elected health and safety representative for the
[Health and Safety Representative name]
having taken reasonable steps to consult with the employer, am of the opinion that the matter has not been
satisfactorily resolved and believe that:
[whoever is contravening the Act - can be the firm, the employer, CEO or an individual]
is contravening/has contravened (and is likely to repeat that contravention), the Occupational Health, Safety
and Welfare Act 1986 at:
[name and address of workplace]
The grounds for my opinion are:
(additional pages may be attached if necessary)
is responsible for remedying
[NAME OF PERSON ADDRESSED: name of company, employer, CEO or nominated responsible officer]
This contravention by am/pm
on / /
Date / /
[Health and Safety Representative]
(Date of issue)
Instructions for using this Notice:
Upon completion, this Notice should be handed to the person addressed or to the employer or their
representative (e.g. supervisor, safety officer) who shall ensure that it is given to the employer who is responsible
for placing copies of it in prominent locations about the affected workplace and informing affected workers of
its content. Health and safety representatives should retain their own copies of Default Notices they issue.
SafeWork SA should be contacted by the health and safety representative if the Notice is not complied with by
the specified date and by the employer if they wish to appeal against the Notice being issued.
Copies of Default Notices must be retained for 3 years.
More information about Default Notices is contained within Safeguard ‘Resolution of health and safety issues’,
which is available from SafeWork SA (see over).