NT WorkSafe Cover Sheet

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Proposed amendments to the NT Workers Rehabilitation
and Compensation Act
Complete and submit this form with your submission by the specified closing date as
outlined on the NT WorkSafe website.
                      Email submissions to

Public or confidential
Do you wish to lodge your submission ‘IN CONFIDENCE’                                     YES                    NO
An ‘IN CONFIDENCE’ submission will be considered but not published on the NT WorkSafe website.

Submission Details – NOTE: The following information WILL be placed on the NT WorkSafe website.
This submission is written on behalf of                                             Please select ONE of the following

Name:                                                                                    Individual             Organisation

Individual / Organisation Details
– NOTE: The following information WILL NOT be placed on the NT WorkSafe website.
Principal contact name:

Contact phone number:                                    Email address:
Are you making this submission as: Please select ONE of the following
   Business                      Union                               Community organisation            OHS Consultant
   Employer organisation         Insurance Company                   Worker                            Other, please specify:
   Industry representative       Government representative           Professional
Which industry sector do you operate in: Please select ONE of the following
    Agriculture, Forestry and Fishing                                 Finance and Insurance
    Mining                                                            Property and Business Services
    Manufacturing                                                     Government Administration and Defence
    Electricity, Gas and Water Supply                                 Education
    Construction                                                      Health and Community Services
    Wholesale Trade                                                   Cultural and Recreational Services
    Retail Trade                                                      Personal and Other Services
    Accommodation, Cafes and Restaurants                              N/A
    Transport and Storage                                             Other, please specify:
    Communication Services

NOTE: Only typed electronic submissions will be accepted. Please contact NT WorkSafe if you wish to submit hand written
submissions on 1800 019115 or via email
Confidential material – Where a submission includes confidential and non-confidential material, the confidential material should
be provided under a separate cover sheet and clearly marked ‘IN CONFIDENCE’ and will not be placed on the website.
Copyright in submissions – Copyright resides with the author(s), not with NT WorkSafe.
Liability – Neither the Northern Territory Government nor NT WorkSafe takes responsibility or shall be liable for any breach of
the copyright, or libellous or defamatory comments in submissions published by NT WorkSafe.

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