Application for a licence to use a scheduled carcinogen

Use this form to apply for, renew or amend a licence to use a scheduled carcinogen.
Last updated

Jun 2017

Reading level


File type and size

PDF, 225.61 kB

Document length

4 pages

What it contains

General Information and Instructions to complete the application

  1. WorkSafe cannot process applications from a person whose identity has not been verified. If you have not previously done so, you must complete and submit an Identification Form – Natural Person or an Identification Form – Non-Individual with this application.
  2. This form is for persons applying for a Licence to use Schedule 10 Carcinogen in a laboratory, or a Schedule 11 Carcinogen in a workplace other than a laboratory, or a Schedule 11 Carcinogen in a laboratory.

The use of a Schedule 1 Carcinogen in a workplace other than a laboratory is prohibited.

  1. Schedule 10 and 11 Carcinogen refers to the Schedules of the OHS Regulations.
  2. A separate application form must be completed for each scheduled carcinogen to be used.
  3. You must complete all parts of the form.

Use this checklist to ensure that your Application is complete:

  • Completed, signed and dated application form;
  • Details of Risk Control Scheduled Carcinogen Licence Measures as required in Part 5; and
  • Completed and signed Identification Form for either Non-Individual or Natural Person

Note: Unsigned or incomplete applications or applications not accompanied by the required documentation may not be processed.