Health and Safety at Work (Infringement Offences and Fees) Regulations 2016

Schedule 2 Form of infringement notice

r 5

Infringement notice

Section 138, Health and Safety at Work Act 2015

Infringement Notice No:

Issuing officer: [name or number]

Address for correspondence and queries:


Full legal name:

Full address:

Date of birth:



Telephone No:

Alleged infringement offence(s) details



Day of week:

Details of premises or specific location where alleged infringement offence(s) committed:



Act or omission that you are alleged to have committed:

This is an offence against [specify provision].

For each offence, specify the following:
Offence numberOffenceInfringement fee payable ($)
Payment of infringement fee(s)

The infringement fee is/fees are* payable within 28 days after [specify earliest day notice delivered personally or posted].

*Select one.
Procedures for payment of infringement fee

[Payment verification stamp]

[Method(s) of payment and address for payment]


If there is anything in these notes you do not understand, you should consult a lawyer.


If you pay the infringement fee(s) within 28 days after the service of this notice, no further enforcement action will be taken against you.


You will have a complete defence against proceedings relating to an alleged offence if the infringement fee is paid to the enforcement authority and received at the address specified for payment within 28 days after the service of a reminder notice in respect of the alleged offence.


Late payment, or payment made to any other address, will not constitute a defence to proceedings in respect of the alleged offence.

Further action

You must write to the enforcement authority at the address specified for correspondence and queries if you wish to do any of the following things:


raise a matter concerning the circumstances of an alleged offence for consideration by the enforcement authority:


deny liability for the alleged offence and exercise your right to request a court hearing:


admit liability for the offence, but have the court consider submissions as to penalty or otherwise. In your letter, you must request a hearing, admit liability in respect of the offence, and set out the submissions that you would like the court to consider.

You must ensure that your request is received on or before the last day for payment.


If you deny liability and request a court hearing, the enforcement authority will, if it decides to commence court proceedings in respect of the alleged offence, serve you with a notice of hearing setting out the place and time at which the matter will be heard by the court.


If you admit liability but wish to have the court consider submissions, the enforcement authority will then, if it decides to commence court proceedings in respect of the offence, file your letter with the court. You are not entitled to make oral submissions to the court.


If the court finds you guilty or if you admit liability and make submissions, costs will be imposed in addition to any penalty.


Each offence identified by a number is a separate infringement offence. You may decide what to do in respect of each alleged offence individually, and may act in the same way in respect of all alleged offences or in different ways in respect of different alleged offences.


If it is not clear which alleged offence any payment relates to, your payment may be treated as relating to the alleged offences in the order in which they are set out in this notice.

Next steps

If you do not request a hearing and you do not pay the infringement fee within 28 days after the service of this notice, a reminder notice will be sent to you. Please note that in some circumstances if you do not receive a reminder notice you may still become liable to pay a fine and court costs.

Note: All payments, queries, and correspondence regarding this infringement notice must be directed to the enforcement authority at the relevant address shown in this notice. When writing, please include the date of the alleged infringement offence, the number of this form (shown above), the full legal name of the notice recipient, and your address for replies.

Michael Webster,
Clerk of the Executive Council.