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REQUEST ASSISTANCE TO
RESOLVE A WORK HEALTH
AND SAFETY MATTER
This request is made under section 99 of the Health and Safety at Work
Act 2015
Your details
Requester name:
Are you making this request as a:
(See the last page of this form for descriptions of these terms)
PCBU HSRWorker
Other
Name of workplace/company/government
department/body corporate:
New Zealand Business Number (NZBN):
(if applicable)
Physical address:
Town/city: Postcode:
Name of contact:
(first name, last name)
Phone number:
Mobile number:
Email:
Details of the health and safety matter
Provide a description of the health and safety matter:
To date, what actions have been taken to resolve this matter:
REQUEST HELP TO RESOLVE A WORKPLACE HEALTH AND SAFETY MATTER
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Provide details of any other involved parties (name, contact number, details of involvement):
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:
Note: the above declaration is considered to be an electronic signature that is reliable as appropriate for the purpose of this notification
Date:
Where to send your completed form
Print, complete and scan this form, or fill in the PDF version. Once completed email it to WorkSafe:
healthsafety.notification@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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