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Provisional Improvement Notice (PIN) Form

About this form

Health and safety representatives (HSRs) have the power (s60) to issue a provisional improvement notice (PIN) if they believe on reasonable grounds that a OHS issue is a breach of the OHS Act or Regulations. A PIN is a written direction requiring a person to remedy the breach (or likely breach). Although it is not compulsory to use a form to issue a PIN, WorkSafe has produced this form to help HSRs provide all the relevant information that is required to issue a valid PIN. For further information on PINs refer to the WorkSafe publication Employee Representation:  A comprehensive guide to Part 7 of the Occupational Health and safety Act 2004

How to complete the form

For guidance on how to complete this form see the back of the PIN form. If further assistance is required, WorkSafe's Advisory Service may be contacted by phoning 9641 1444 (toll free 1800 136 089) or emailing

Providing HSR contact details on the bottom of the form will assist an inspector in reaching the HSR should the PIN be disputed by the person to whom it was issued. HSRs are advised to keep a copy of the completed form for their records. 

Hard copy PIN forms in triplicate may also be ordered through WorkSafe's Advisory Service.