National Asbestos Register Form
Asbestos Exposure Register Form
What is the National Asbestos Register?
The National Asbestos Register is a databaseestablished andmaintained by The Australian Workers' Union and Maurice Blackburn. It is a free service that enables people to make a formal record of their asbestos exposure should the information be required in the future.There are currently more than 6,000 registrants, and as the database becomes bigger it also becomes more useful - for you as well as for other victims of asbestos related diseases.
Personal Details
Given Names
Surname
Date of Birth (dd/mm/yyyy)
Street Address
Suburb
State
Postcode
Telephone - Home
Mobile
Email Address
Please tick where you were exposed to asbestos:
Home
Work
Other
Please describe your exposure in as much detail as possible:
Have you been diagnosed with an asbestos related disease?
Yes
No
If Yes, please indicate which disease:
Mesothelioma
Lung Cancer
Asbestosis
Pleural Plaques
Other (please name)
Other Disease
If Possible, provide the names of two people who can confirm your exposure
1
2
How did you find out about the AWU Asbestos Register?
Newspaper
Union
Friend
General Reputation
Other (please specify below)
Other
please complete code