Page 1 of 2
REQUEST TO REVIEW A
PROVISIONAL IMPROVEMENT
NOTICE (PIN)
This request is made under section 79 of the Health and Safety at Work
Act 2015
Your details
Name of Person Conducting Business or
Undertaking (PCBU)
(individual or business name):
New Zealand Business Number (NZBN):
(if applicable)
Physical address:
Town/city: Postcode:
Email:
Name of contact:
(first name, last name)
Mobile number:Phone number:
Details of the Health and Safety Representative (HSR)
Issuing HSR:
(first name, last name)
Date of PIN issue:
Phone number:
Mobile number:
Email:
Details of the PIN
I have attached a copy of the original PIN
Provide a brief description of why the PIN was issued:
Provide a brief description of why the PIN should be reviewed, include any new additional information:
REQUEST TO REVIEW A PROVISIONAL IMPROVEMENT NOTICE (PIN)
Page 2 of 2
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 or the person the PIN was issued to and therefore am authorised to make this
request.
Name:
(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
Date:
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.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome