REQUEST REMOVAL OF
A HEALTH AND SAFETY
REPRESENTATIVE
This request is made under Schedule 2, clause 19 of the Health and
Safety at Work Act 2015.
Person Conducting Business or Undertaking (PCBU) details
Name of PCBU requesting removal:
(individual or business name)
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 Representative (HSR) that you are asking WorkSafe to remove
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Name of HSR:
(first name, last name)
Phone number:
Mobile number:
Email:
Has the HSR been NZQA qualified to use their powers?
Yes No
Why are you requesting the removal of this HSR:
Provide a summary of the discussions had with the HSR about the above issue:
Attach any relevant information to support this request
REQUEST REMOVAL OF A HEALTH AND SAFETY REPRESENTATIVE
Declaration
I declare that to the best of my knowledge, the information provided in this request is true and correct.
I confirm that I am the PCBU and therefore am authorised to make this request.
Name:
Date:
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
WorkSafe branch:
Whangarei
whangarei@worksafe.govt.nz
Albany
albany@worksafe.govt.nz
Auckland Central
aucklandcentral@worksafe.govt.nz
Manukau
manukau@worksafe.govt.nz
Hamilton
hamilton@worksafe.govt.nz
Tauranga
tauranga@worksafe.govt.nz
Rotorua
rotorua@worksafe.govt.nz
Gisborne
gisborne@worksafe.govt.nz
New Plymouth
newplymouth@worksafe.govt.nz
Napier
napier@worksafe.govt.nz
Palmerston North
palmerstonnorth@worksafe.govt.nz
Wellington
wellington@worksafe.govt.nz
Nelson
nelson@worksafe.govt.nz
Greymouth
greymouth@worksafe.govt.nz
Christchurch
christchurch@worksafe.govt.nz
Timaru
timaru@worksafe.govt.nz
Dunedin
dunedin@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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