We value your feedback.
If you require general information not currently available on this site, or were not able to find what you were looking for, you can contact the webmaster.
Otherwise send us your feedback or lodge an official complaint so that we can ensure this site meets your needs.

Mining Safety and Health Forms
Application and notification forms related to certificates of competency, mutual recognition, occupational health, exploration operations, PINs, safety and health representatives, and freedom of information (FOI).
Unless otherwise indicated, mail completed forms to:
Resources Safety
Department of Mines and Petroleum
100 Plain Street
East Perth WA 6004
If you wish to lodge forms in person, visit the Resources Safety office at:
303 Sevenoaks Street (Cnr Grose Avenue)
Cannington WA 6107
Office hours: 8:30 am to 4:30 pm
Page Contents
How to request permission to reproduce Resources Safety material
Certificates of competency application forms
Mutual recognition application
Occupational health related forms
Inspectorate contact details for appointment notifications
Appointments notified by Principal Employer
Appointments notified by Registered Manager
Appointments advised by Registered Manager
Other mining-related application and notification forms
How to request permission to reproduce Resources Safety material
Copying and distributing complete (i.e. including copyright notices and disclaimers) and unaltered Resources Safety materials are permitted without formal approval.
However, reproduction in any other form or partial reproduction of any material published in print or electronically must be approved by Resources Safety's Communications Manager. To request permission, download the request to reproduce Resources Safety material form below or call +61 (08) 9358 8149 for further information.
Certificates of competency application forms
Certificate of competency application forms are provided below. Fact sheets on requirement details (including examination process) are provided in the Publications > Mining Safety and Health section.
- Authorised mine surveyors certificate - application form(PDF 944 kb)
- Copy of a certificate - application form(PDF 247 kb)
- First class mine manager certificate - application form(PDF 846 kb)
- Quarry manager certificate - application form(PDF 1255 kb)
- Restricted quarry manager certificate (explosives) - application form(PDF 1446 kb)
- Restricted quarry manager certificate (non-explosives) - application form(PDF 1462 kb)
- Underground supervisor certificate - application form(PDF 1061 kb)
- Statutory declaration(PDF 237 kb)
- Winding engine driver's health certificate(PDF 2135 kb)
Mutual recognition application
Guidelines on applying for mutual recognition of Australian and New Zealand (Trans-Tasman) occupations are included in the relevant application form.
Occupational health related forms
When completing a "CONTAM system sample record sheet" also see: Guide to electronic submission of the CONTAM system sample record sheet.
- Approval as a noise officer - application form(PDF 197 kb)
- Biological monitoring results form(PDF 70 kb)
- CONTAM system registered sampler form(PDF 681 kb)
- CONTAM system sample record sheet(PDF 87 kb)
- CONTAM system workforce survey(PDF 242 kb)
- Notification of a noise report(PDF 207 kb)
- Notification of occupational disease(PDF 144 kb)
- Personal noise exposure recordings(PDF 65 kb)
Inspectorate contact details for appointment notifications
Appointments notified by Principal Employer
Please note that the pro formas include hidden text and you will need to activate this option in your word processing program.
- Notification of Principal Employer - template(DOC 177 kb)
- Notification of appointment of Registered Manager - template(DOC 33 kb)
- Notification of appointment of Alternate Registered Manager - template(DOC 33 kb)
- Notification of appointment of Underground Manager - template(DOC 34 kb)
- Notification of appointment of Alternate Underground Manager - template(DOC 34 kb)
- Notification of appointment of Quarry Manager - template(DOC 34 kb)
- Notification of appointment of Alternate Quarry Manager - template(DOC 34 kb)
- Notification of appointment of Exploration Manager - template(DOC 33 kb)
- Notification of appointment of personnel involved in management of exploration actvities - template(DOC 34 kb)
Appointments notified by Registered Manager
Under section 33A of the Mines Safety and Inspection Act, a Principal Employer may authorise a Registered Manager to make the appointments required under sections 34(1), 35(1), 36(1) or (2), 37(1), 38(1) or (2) or (3), and 39(2) of the Act. The following pro formas have been provided where this authorisation has been given.
Please note that the pro formas include hidden text and you will need to activate this option in your word processing program.
- Notification of appointment of Alternate Registered Manager by RM - template(DOC 33 kb)
- Notification of appointment of Underground Manager by RM - template(DOC 34 kb)
- Notification of appointment of Alternate Underground Manager by RM - template(DOC 34 kb)
- Notification of appointment of Quarry Manager by RM - template(DOC 34 kb)
- Notification of appointment of Alternate Quarry Manager by RM - template(DOC 34 kb)
- Notification of appointment of Registered Manager as Exploration Manager - template(DOC 33 kb)
- Notification of appointment of Ventilation Officer by RM - template(DOC 32 kb)
Appointments advised by Registered Manager
Notification of the appointments below is not a regulatory requirement. However, the Registered Manager may wish to advise Resources Safety to assist in efficient communication with the Mines Inspectorate.
Please note that the pro formas include hidden text and you will need to activate this option in your word processing program.
- Notification of appointment of Deputy Registered Manager or Alternate Registered Manager - template(DOC 33 kb)
- Notification of appointment of Deputy Underground Manager - template(DOC 33 kb)
- Notification of appointment of Radiation Safety Officer - template(DOC 32 kb)
- Notification of appointment of Electrical Supervisor - template(DOC 33 kb)
- Notification of appointment of Mine Surveyor - template(DOC 32 kb)
- Notification of appointment of Noise Officer - template(DOC 33 kb)
- Notification of appointment of High Voltage Operator - template(DOC 33 kb)
Other mining-related application and notification forms
Notes:
- When applying to register classified plant, also see the Procedure for registering classified plant on mining operations.
- When reporting alleged bullying at a mining workplace, also see the Frequently asked questions on bullying, aggression and violence.
- When submitting a proposal for a high voltage (HV) installation, also see the HV submissions information in the electrical safety one-stop shop.
- Application for shaft sinking and winding installation - pro forma(DOC 546 kb)
- Application for exemption under MSI Regulations - pro forma(PDF 71 kb)
- Approval as a noise officer - application form(PDF 197 kb)
- Dangerous goods incident report form(PDF 124 kb)
- Exploration operation notification form(PDF 59 kb)
- Notification of change in mine operating status - template(DOC 44 kb)
- Notification of high voltage installation - pro forma(DOCX 178 kb)
- Provisional improvement notice (PIN) for use by safety and health reps - pro forma(PDF 147 kb)
- Referral of improvement notice for review(PDF 192 kb)
- Referral of prohibition notice for review(PDF 234 kb)
- Registration of classified plant (all types) - pro forma (DOC 118 kb)
- Reporting alleged bullying at a mining workplace - pro forma(PDF 297 kb)
- Request for access to mine plans(PDF 34 kb)
- Safety and health representative(s) notification of election form(PDF 56 kb)
- Small mine checklist - template(DOC 279 kb)
Freedom of information application
The following form includes detailed information on making an FOI application, including fees and charges.
Schedule of fees and charges
Fees and charges related to resources safety (including dangerous goods and mining) are provided in the document below:











