Register an individual

Friends and relatives can voluntarily register the name of an individual or loved one who has died as a result of a work-related accident, incident or disease to be published on the National Workers Memorial Honour Roll.

To register an individual, complete our webform:

Registration form

Person submitting the form

Name:

Please provide at least one contact for yourself

Email contact:

Phone contact:

Relationship to the deceased

I am not aware of any current legal action regarding the death of the individual I wish to register for inclusion on the Honour Roll.

I am aware of current legal action regarding the circumstances of the death of the individual I wish to register for inclusion on the Honour Roll. The details of the legal action are below (e.g. what type of legal action, which court the proceedings are in, when is the action expected to be resolved).

I have read and understood the criteria for inclusion on the Honour Roll and consider that this individual meets the criteria.

The criteria can be found at the About the Honour Roll page.

Details of the deceased

First Name:

Surname:

Nickname (optional):

Aboriginal Descent

Torres Strait Islander Descent

If the deceased is of Aboriginal or Torres Strait Islander descent, does the deceased's family support their inclusion on the Honour Roll.

Yes

*Please note that individuals of Aboriginal or Torres Strait Islander descent whose inclusion on the Honour Roll is not supported by their family may not be included on the Honour Roll.

Location of fatality, e.g. Sunshine Coast, Queensland.

Date of fatality:

Declaration, consent and acknowledgement of person submitting the form

I declare that the information I have provided is true and accurate and that I am aware that providing misleading, deceptive, or false representations can amount to a criminal offence and give rise to civil liability.

I consent to my personal information being used or disclosed for the purposes of administering the Honour Roll and related purposes, including assessing and validating applications. I acknowledge my personal information will not be used for purposes other than this or disclosed to third parties without my consent.

Name:

Date

Contact

Get in touch with the Contact page for any enquiries.

National Workers Memorial