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REQUEST AN INTERNAL
REVIEW OF A REVIEWABLE
DECISION
This request is made under Section 131 of the Health and Safety at
Work Act 2015
Important: A review request must be made before the period specified in the Improvement Notice for compliance (if applicable), or 14 days;
whichever is the lesser. In certain situations WorkSafe may accept this form after the periods specified above; contact WorkSafe for more
information.
Your details
PCBU Worker HSR
Other
Are you making this request as a:
(See the last page of this form for descriptions of these terms)
Name of person requesting review:
(This could be an individual or a legal business name)
New Zealand Business Number (NZBN):
(if applicable)
Physical address:
Town/city: Postcode:
Name of contact:
(If different to above)
Phone number: Mobile number:
Email:
Details of the reviewable decision
Select the type of decision that this review request relates to:
Issue of Notice:
Improvement Prohibition
Extension of improvement notice compliance period
Non-disturbance (or subsequent)
Provisional Improvement Notice (PIN) review
Issuing Inspector:
(first name, last name)
Date of issue:
Provide a description of how you are affected by the decision, and why the decision should be reviewed:
Would you like WorkSafe to consider staying the
original decision while its review is completed?
Yes
No
I have attached any additional information relating to why the decision should be reviewed; or why
WorkSafe should consider staying the decision.
Health and Safety Representative (HSR) details
There is an HSR working for this organisation They are NZQA qualified to use their powers
Declaration
I declare that to the best of my knowledge, the information provided in this request is true and correct.
Name:
(first name, last name)
Date:
Note: the above declaration is considered to be an electronic signature that is reliable as appropriate for the purpose of this notification
REQUEST AN INTERNAL REVIEW OF A REVIEWABLE DECISION
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Where to send your completed form
Print, complete and scan this form, or fill in the PDF version. Once completed, email it to your nearest
WorkSafe branch:
Whangarei
whangarei@worksafe.govt.nz
Napier
napier@worksafe.govt.nz
Albany
albany@worksafe.govt.nz
Palmerston North
palmerstonnorth@worksafe.govt.nz
Auckland Central
aucklandcentral@worksafe.govt.nz
Wellington
wellington@worksafe.govt.nz
Manukau
manukau@worksafe.govt.nz
Nelson
nelson@worksafe.govt.nz
Hamilton
hamilton@worksafe.govt.nz
Greymouth
greymouth@worksafe.govt.nz
Tauranga
tauranga@worksafe.govt.nz
Christchurch
christchurch@worksafe.govt.nz
Rotorua
rotorua@worksafe.govt.nz
Timaru
timaru@worksafe.govt.nz
Gisborne
gisborne@worksafe.govt.nz
Dunedin
dunedin@worksafe.govt.nz
New Plymouth
newplymouth@worksafe.govt.nz
Invercargill
invercargill@worksafe.govt.nz
If emailing this form is not practical, you may post it to:
The Registrar
WorkSafe New Zealand
PO Box 105-146
Auckland 1143
Terms
PCBU — A PCBU is a ‘person conducting a business or undertaking’. A PCBU may be an individual person or an
organisation. It does not include workers or officers of PCBUs, volunteer associations with no employees, or
home occupiers that employ or engage a tradesperson to carry out residential work. A PCBU must ensure, so far
as is reasonably practicable, the health and safety of workers, and that other persons are not put at risk by its
work. This is called the ‘primary duty of care’.
Worker — A worker is an individual who carries out work in any capacity for a PCBU. It includes an employee, a
contractor or sub-contractor, an apprentice or trainee, a person on work experience or a work trial, or a
volunteer worker. Workers have their own health and safety duty to take reasonable care to keep themselves
and others healthy and safe when carrying out work.
HSR - A Health and Safety Representative (HSR) is a worker who has been elected by the members of their
work group to represent them in health and safety matters. HSRs are elected by a work group, which is a
defined group of workers who work for the PCBU.
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