Supervisors Details

Form 65 asbestos is a fire retardant that was once commonly used in building materials. However, over time it has been found to cause health problems, including cancer. If you believe you may have been exposed to form 65 asbestos, it is important to seek medical attention right away. This article will discuss the dangers of form 65 asbestos and provide tips on how to protect yourself from exposure.

The table includes information about the form 65 asbestos. It is definitely worth taking a few minutes to read through this prior to starting filling out your form.

QuestionAnswer
Form NameForm 65 Asbestos
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names

Form Preview Example

FORM 65

V25.1.12

Notification of licensed asbestos removal work

ABN 13 846 673 994

Work Health and Safety Act 2011

(to be completed by licensed asbestos removalist at least five calendar days before licensed asbestos removal work commences)

1. Licensed removalist

Name that appears on the asbestos removalist licence

Licence number

 

 

Licence expiry date

/

/

 

 

 

 

 

 

Licence class

 

A class licence

 

B class licence

 

 

 

 

 

 

 

 

State / territory / Commonwealth that issued the licence

 

 

 

 

 

 

 

 

 

 

Registered business name of the licence holder

 

 

 

 

 

 

 

 

 

ABN:

 

 

 

 

 

 

 

 

Business contact details

 

Working hours: (

)

Mobile:

 

 

 

 

 

 

 

 

 

2. Supervisor for asbestos removal work

Name of supervisor for the asbestos removal work

Mr / Mrs / Miss / Ms

First name

 

 

Surname

 

 

 

 

 

Supervisor’s contact details

Working hours: (

)

 

Mobile:

 

 

 

 

 

3. Person to conduct inspection and issue clearance certificate

Person conducting clearance inspection and

Asbestos assessor (must be licensed

Competent person

certificate is a:

after 31/12/2013)

 

 

 

 

 

 

Name of the person/s who will be inspecting and issuing the clearance certificate (if known)

 

Mr / Mrs / Miss / Ms

 

 

 

First name

 

Surname

 

 

 

 

 

Contact phone number

Phone: (

)

Mobile:

 

 

 

 

4. Client or person for whom the work is being performed

Client name

 

 

 

 

 

 

 

 

 

 

Mr / Mrs / Miss / Ms

 

 

 

 

 

 

 

 

 

 

 

First name

 

 

 

 

Surname

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact phone number

Phone: (

)

 

 

Mobile:

 

 

 

 

 

 

 

 

 

 

 

Trading name of business / person in control of the workplace

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address where the asbestos removal will take place

 

 

 

 

 

 

 

No

Street name

 

 

 

 

 

 

Street type

 

Suburb

 

 

 

 

 

State

 

Postcode

 

 

 

 

 

 

 

 

 

 

 

Specific location within the site (If the site is a large workplace)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of place/plant (eg. domestic premises, shopping centre, child care centre, plant)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date the asbestos removal work is expected to commence:

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date the asbestos removal work is expected to finish:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of asbestos to be removed

 

 

Friable

 

 

 

 

 

Non-friable (bonded)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Estimated quantity of asbestos to be removed (m2, kg, bags)

 

 

 

 

 

JAG 11/4257

 

 

 

 

 

 

 

 

 

 

 

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5. Details of work methods

Number of workers to be used for the asbestos removal work:

Name and competency details of the workers used for the asbestos removal work

(refer fact sheet Asbestos transitional arrangements for competency information):

First Name

Surname

Competency Details

If friable asbestos is to be removed, describe the method to be used (e.g. the way the area of removal will be enclosed, specific wet method)

Describe actions taken/to be taken to advise neighbours of intended asbestos removal work

6. Person completing this form

Your name

 

 

 

 

 

 

Mr / Mrs / Miss / Ms

 

 

 

 

 

 

First name

 

 

Surname

 

 

 

 

 

 

 

 

 

Position within business or undertaking

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact phone number:

Phone: (

)

 

Mobile:

 

 

 

 

 

 

 

 

 

Signature (not required where lodged via email)

 

 

Date:

/

/

 

 

 

 

 

 

 

Lodging your notification

Submit your completed notification to Advisory and Assessment Centre, Office of Fair and Safe Work Queensland by email, fax or post.

Email : whsnotification@justice.qld.gov.au or

Facsimile: (07) 3872 0501

Post: Office of Fair and Safe Work Queensland

PO Box 820

LUTWYCHE QLD 4030.

PRIVACY STATEMENT: The Department of Justice and Attorney-General collects, uses, discloses and stores information in accordance with legislation it administers and all applicable privacy laws. This includes information collected by inspectors of the Department. Note that privacy laws do not apply if other laws conflict or allow or require the collection of information, and do not apply to the collection of information by Department of Justice and Attorney-General to the extent that it is exercising its law enforcement functions and non-compliance with privacy legislation is deemed necessary to fulfil those functions. The Department of Justice and Attorney-General privacy information is on our website at www.justice.qld.gov.au.

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JAG 11/4257

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