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Notifiable Event notification form

Use this form to notify WorkSafe New Zealand of a notifiable event as required by Section 56 of the Health and Safety at Work Act 2015. As defined in the act, a notifiable event means any of the following events that arise from work:

(a) the death of a person; or
(b) a notifiable injury or illness; or
(c) a notifiable incident

If you want to notify WorkSafe NZ of particular hazardous work, please click on the following link: http://forms.worksafe.govt.nz/hazardous-work-notification

What would you like to notify WorkSafe NZ of?
PCBU details
No Yes
Reporter details
No Yes
No Yes
* I declare that to the best of my knowledge, the information provided in this notification 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