Notification Of Licensed Asbestos Removal

Use this form to notify WorkSafe New Zealand of upcoming licensed asbestos removal work, as required by the Health and Safety at Work (Asbestos) Regulations 2016 regulation 34.

Notification must be given to WorkSafe at least 5 days before work commences.

If the asbestos requires immediate removal as defined by the Health and Safety at Work (Asbestos) Regulations 2016 regulation 34(2), notice must be given to WorkSafe immediately by telephone (0800 030 040) and in writing within 24 hours of the call.

* Mandatory

Yes No
(A sudden and unexpected event that could expose a person to respirable asbestos fibres or a breakdown of essential services that requires immediate fixing)
Yes No

Licence holder details


(as it appears on licence)
  • Supervisor details


    (if a current asbestos Certificate of Competence holder)

Clearance inspection

Independent licensed asbestos assessor or competent person details


(if applicable)

(if applicable)

Person or organisation for whom the work is being carried out

(eg. Property or site owner)



(if different from above)

(if applicable)

PCBU with management or control of the workplace

(the person or organisation managing the workplace eg. tenant / building owner / lead contractor / project manager)



(if different from above)

(if applicable)

(physical address of the location where asbestos will be removed)




(describe in detail, i.e. air conditioning pipes in the ceiling space of the 3rd floor, West Block)

(i.e. classroom in a primary school, administrative office in a factory, living room in a home)

Notification dates

*
(in days)

Work details

Friable, specify below how the removal area will be enclosed
Non-friable

Worker details

For each worker fill out the details of the worker's competency to carry out asbestos removal work

  • Worker

    Yes No

Declaration*

I declare that to the best of my knowledge, the information provided in this request is true and correct *
Note: the above declaration is considered to be an electronic signature that is reliable as appropriate for the purpose of this notification.