REQUEST ASSISTANCE TO RESOLVE A WORKPLACE HEALTH AND SAFETY MATTER CAUSING CESSATION OF
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I have attached any supporting information (photographs or diagrams).
(supporting information is not mandatory but should be supplied when helpful in explaining the health and safety matter)
Health and Safety Representative (HSR) details
There is an HSR working for this organisation They are NZQA qualified to use their powers
I declare that to the best of my knowledge, the information provided in this request is true and correct.
(first name, last name)
Note: the above declaration is considered to be an electronic signature that is reliable as appropriate for the purpose of this notification
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
If emailing this form is not practical you may post it to:
WorkSafe New Zealand
PO Box 105-146
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.