● Ground Floor, 445 Hay Street, Perth    ● PO Box 3114, East Perth WA 6892
COVID-19 vaccinations – Q and As for WA workers

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    Further information about your circumstances

    Instructions for using this form
      • Please fill in as much information as you can. It's okay if you don't know the answers to all these questions. However, the more information you give us, the easier it is for us to help you.
      • Some questions are marked "required" which means you must try to answer them before you can send this form.
      • If you don't understand the form or are having trouble filling it out, you can call us on (08) 6148 3636 to request a team member call you back to go through the form with you over the phone instead.
    Privacy statement
    You should have read our privacy statement when you made your online enquiry. If you did not, you can access it below. It's important that read the privacy statement before providing your details to us. Click here to read the privacy statement. We do not provide advice by email. If you have a disability that prevents you from speaking to us on the phone, please let us know in the form below.

    If you cannot read or don't understand the privacy statement you should call our Advice Line instead. If you are eligible to receive legal advice, a member of staff can explain the privacy statement to you.

    Click here for information on how to call our Advice Line.

    Personal details

    Enter your full name. We are unable to provide advice if you do not give your full name.

    Please provide a telephone number we can call you on to provide assistance. It is important that this number is safe for us to contact. Please avoid providing a work number.

    We will only call this number if we can't get through to you on the first number you have provided above.

    Please provide an email address that is safe for us to contact and that you check regularly.

    Please provide an address that is safe for us to contact if we cannot contact you by telephone or email.

    If you don't know the exact amount you've earned in the last 12 months, please make your best estimate.

    If your current income is different than your income in the last 12 months, please provide your current income here.

    Please choose the option that best describes your current relationship status.

    If you don't know the exact amount your partner earned in the last 12 months, please make your best estimate.

    A dependant is a child or another person who relies on your financial support.

    Employer details

    An "ABN" is an Australian Business Number. You can normally find your employer's ABN on your payslips or group certificate. We will still accept your application if you don't know your employer's ABN, however you should make an effort to find it as we may not be able to provide accurate advice without it. If your issue is with a previous employer, enter that employer's ABN, not your current employer.

    If your issue is to do with a previous employer - enter the name of your previous employer, not your current employer.

    Employment details

    If you don't know what an award or registered agreement is, please select I don't know and we may be able to help you with this.

    If you are not sure of the exact date, please provide your best estimate (or a month and year).

    If you are not sure of the exact date, give us your best estimate.

    If you are not sure of the exact date, give us your best estimate.

    Problem or issue details

    Enter the full names of any one else directly involved in the issue or issues you are having.

    Check any boxes that you think apply to any of the problems/issues you are experiencing at work. If none apply, describe your problem or issue in the next section.

    Please briefly outline the problem or issue you are having at work. Your entry is limited to approximately 300 words. We will be able to take more complete instructions from you when we call you.

    Please write down the questions you want answered

    Contact time

    If there is a time, or times that you are not available for an employment law advice call, please tick the boxes below. If you have limited availability, you may have to wait longer for advice.

    Please note we may be calling from a blocked number with no caller ID. Please make your best efforts to answer your phone over the coming period. If we cannot successfully call you after 3 attempts, you will receive an email requesting that you resubmit your online enquiry.

    If you cannot, or would prefer not to accept a phone call because of a hearing impairment or other disability, please check the box at the bottom of the list.

    Unavailable days / times

    Please select all days / times you are NOT available for an employment law advice call:

    Referral pathway

    I declare that everything in this form is true and correct. I understand that I may be asked to provide evidence verifying the information I have provided, and agree to provide such evidence if asked.
    Providing false information can make it difficult for us to provide accurate advice