Request for household help services (PDF)

This form is for treating health practitioners to request household help or gardening services for a worker.

Download the PDF before filling it in

Important: Please download this PDF to your computer. You can fill it in using Adobe Reader as it may not save if you attempt to fill it in using your web browser.

Published: 01 Aug 2024

File type: PDF

File size: 210.99 kB

Length: 3 pages

Reading level: Medium

What it contains

Information about how to apply for services.

The form should include:

a capacity assessment
an explanation of how the service will help the worker
the household service(s) requested
any other relevant information

Request for household help services (PDF)

What it contains

Household help request: Worker declaration (PDF)

Information

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Request for household help services (PDF)

What it contains

Household help request: Worker declaration (PDF)

WorkSafe Victoria