introduction_text: '#type': processed_text '#text': '

Report suspected fraud

This form allows you to provide information to WorkSafe Victoria (WorkSafe) about a person you think is getting a payment or benefit from WorkSafe they should not be getting. WorkSafe will assess the information provided and take appropriate action.

' '#format': rich_text container_your_details: '#type': container your_details_heading: '#type': processed_text '#text': '

Your details

You may choose to remain anonymous. However providing your details will assist Investigators if they need to contact you for further information.

' '#format': rich_text i_wish_to_remain_anonymous: '#type': checkbox '#title': 'I wish to remain anonymous' container_non_anonymous_details: '#type': container your_name_flexbox: '#type': webform_flexbox your_first_name: '#type': textfield '#title': 'Your first name' your_last_name: '#type': textfield '#title': 'Your last name' details_flexbox: '#type': webform_flexbox telephone_number: '#type': tel '#title': 'Your phone number' '#international': true '#international_initial_country': AU '#international_preferred_countries': - AU your_email: '#type': email '#title': 'Your email' container_about_the_person: '#type': container about_the_person_heading: '#type': processed_text '#text': '

About the person

Please provide as much information as you can about the person you are reporting. If you cannot provide an answer, proceed to the next question.

' '#format': rich_text about_the_person_name_flexbox: '#type': webform_flexbox family_name_of_the_person: '#type': textfield '#title': 'Family name of the person' first_name_of_the_person: '#type': textfield '#title': 'First name of the person' age_flexbox: '#type': webform_flexbox date_of_birth: '#type': date '#title': 'Date of birth' age: '#type': number '#title': 'Age (or approximate)' '#min': 16 '#max': 120 persons_address: '#type': webform_address '#title': 'Current address of the person' '#state_province__title': State '#country__access': false gender_of_the_person: '#type': radios '#title': 'Gender of the person' '#options': Female: Female Male: Male 'Other or unknown': 'Other or unknown' '#options_display': side_by_side flexbox_inury: '#type': webform_flexbox date_or_year_of_injury: '#type': date '#title': 'Date of injury' claim_number: '#type': textfield '#title': 'Claim number' additional_information: '#type': textarea '#title': 'Additional Information about the person you are reporting' '#description': 'This could include physical characteristics of the person or the person''s car registration number etc.' '#help_title': 'This could include physical characteristics of the person or the person''s car registration number etc.' container_employer: '#type': container employer_heading: '#type': processed_text '#text': '

Injury employer

' '#format': rich_text employer_name: '#type': textfield '#title': 'Employer name' employer_address: '#type': webform_address '#title': 'Employer address' '#address_2__access': false '#state_province__title': State '#country__access': false type_of_business: '#type': textfield '#title': 'Type of business' container_suspected_work_activities: '#type': container suspected_work_heading: '#type': processed_text '#text': '

Suspected work activities

' '#format': rich_text has_the_person_been_performing_any_work_activities_paid_or_unpai: '#type': radios '#title': 'Has the person been performing any work activities (paid or unpaid) that you are aware of' '#options': 'Yes': 'Yes' 'No': 'No' Unsure: Unsure '#options_display': side_by_side container_suspected_yes: '#type': container '#states': invisible: ':input[name="has_the_person_been_performing_any_work_activities_paid_or_unpai"]': value: 'No' suspected_yes_intro: '#type': processed_text '#text': '

If yes, please provide the below information:

' '#format': rich_text suspected_employer_name: '#type': textfield '#title': 'Employer name' suspected_employer_address: '#type': webform_address '#title': 'Employer address' '#address_2__access': false '#state_province__title': State '#country__access': false suspected_type_of_business: '#type': textfield '#title': 'Type of business' suspected_type_of_work_the_person_is_performing: '#type': textfield '#title': 'Type of work the person is performing' suspected_full_time_or_part_time_work_: '#type': radios '#title': 'Full-time or part-time work?' '#options': Full-time: Full-time Part-time: Part-time Casual: Casual Unsure: Unsure '#options_display': side_by_side days_worked_please_select_all_that_apply_: '#type': checkboxes '#title': 'Days worked (please select all that apply)' '#options': days suspected_additional_information: '#type': textarea '#title': 'Additional information about the person you are reporting' '#description': 'This could include a description of a uniform worn, the time of day the person works etc.' '#help_title': 'This could include a description of a uniform worn, the time of day the person works etc.'

Form test page

What this is used for

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