Forms and templates

​​​​To support implementation of the Public Health Act 2010 (the Act) and the Public Health Regulation 2022 (the Regulation), the NSW Ministry of Health has developed a range of forms and templates for local government authorities and Public Health Units and, where appropriate, industry stakeholders.

Reporting

Local government authorities are required to report the details of improvement notices and prohibition orders served under the Act (on or before 1 August each year). The report template can be found at Local Government Authority Reporting.

Notification forms

The Regulation requires operators of certain activities to notify the local government authority about their operations. The following notification forms are provided for this process:

• Notification of premises where skin penetration procedures are carried out
• Notification of premises where a public swimming pool and/ or spa pool is installed
• Notification of premises where a cooling water system or warm water system is installed
• Notification of premises where a mortuary is operating

Inspection forms

The following inspection forms have been developed to support local government authorities and public health units. Industry stakeholders may also wish to use these tools to ensure they are meeting their obligations under the Act and Regulation.

• Swimming pool and spa pool inspection form
• Cooling water system operation and maintenance inspection form - fillable
• Cooling water system operation and maintenance inspection form - nonfillable
• Checklist for receiving RMPs and Audits
• Skin penetration inspection form
• Mortuary inspection form - Public Health Regulation
• Mortuary inspection form - Local Government (General) Regulation
• Warm water system installation inspection form
• Warm water system operation and maintenance inspection form
• Cooling water system installation inspection form

Improvement notice templates

The following improvement notice templates have been developed to support Authorised Officers to serve an improvement notice, under sections 41 and 42 of the Act, if the officer believes, on reasonable grounds, that an enforceable requirement is not being complied with. Authorised Officers will need to change this template to include information that relates to the subject of the notice.

• Improvement notice - Skin penetration
• Improvement notice - Public swimming pool or spa pool
• Improvement notice - Regulated system

Prohibition order templates

The following prohibition order templates have been developed to support Authorised Officers to serve a prohibition order, pursuant to section 45 of the Act. A prohibition order remains in force until a certificate of clearance is issued. A prohibition order can only be issued if the Secretary of the Ministry of Health, a local government authority, or the General Manager of a council believes on reasonable grounds that:

1. that any of the circumstances in which an improvement notice may be issued exist and that:
   1. the occupier has not complied with an improvement notice within the time required under the notice, and
   2. the issue of the prohibition order is necessary to prevent or mitigate a serious risk to public health, or
2. that any of the circumstances in which an improvement notice may be issued exist and that the issue of the prohibition order (without first issuing an improvement notice) is urgently necessary to prevent or mitigate a serious risk to public health.

Authorised Officers will need to change this template to include information that relates to the subject of the order.

• Prohibition order - Skin penetration
• ​Prohibition order - Public swimming pool or spa pool​
  
• Prohibition order - Regulated system

Certificate of clearance templates

If a prohibition order has been issued, it remains in force until a Certificate of clearance is issued by the Secretary of the Ministry of Health, the local government authority, or the General Manager of a council. A Certificate of clearance means that an Authorised Officer has inspected the premises and is satisfied that there is no serious danger to public health. Authorised Officers will need to change this template to include information that relates to the subject of the order.

• Certificate of clearance - Skin penetration
• Certificate of clearance - Public swimming pool or spa pool
• Certificate of clearance - Regulated system

Approved forms for Legionella control in cooling water systems

The Regulation requires six approved forms to be used to document certain aspects of managing a cooling water system. Visit our Legionella control page for further information.