Notification of Licensed Asbestos Removal -WorkSafe New Zealand

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

Does this information relate to the immediate removal of asbestos work?*

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)

Have you given notice to WorkSafe by telephone?*

Yes No

Licence holder details

Name of licence holder*
(as it appears on licence)

Asbestos removal licence number OR Certificate of Competence number OR WKSL number*

Business contact number*

Email*

Supervisor details

Title

Last name*

First name*

Middle names

Business contact number*

Email*

Clearance inspection

Independent licensed asbestos assessor or competent person details

Title

Last name*

First name*

Middle names

Assessor licence number
(if applicable)

Assessor licence expiry
(if applicable)

Person or organisation for whom the work is being carried out

(eg. Property or site owner)

Full legal name*

Trading name
(if different from above)

New Zealand Business Number (NZBN)
(if applicable)

Business contact number*

Contact name*

PCBU with management or control of the workplace

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

Full legal name*

Trading name
(if different from above)

New Zealand Business Number (NZBN)
(if applicable)

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

Street address 1*

Street address 2

Locality/Suburb*

Region/City*

Where in the workplace is the asbestos located?*
(describe in detail, i.e. air conditioning pipes in the ceiling space of the 3rd floor, West Block)

What kind of workplace is it?*
(i.e. classroom in a primary school, administrative office in a factory, living room in a home)

Notification dates

Date notified Worksafe*

Work start date*

Estimated duration of work*
(in days)

Work details

Type of asbestos being removed*

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

What is the estimated quantity of asbestos to be removed?*

Specify how the asbestos waste will be transported and disposed of*

Worker details

How many workers are carrying out the removal work?*

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

Worker

Title

Last name*

First name*

Middle names

Holds certificate in relevant training*

Yes No

Summary of training*

Declaration*

I declare that to the best of my knowledge, the information provided in this request is true and correct *

Full legal name*

Date*

Note: the above declaration is considered to be an electronic signature that is reliable as appropriate for the purpose of this notification.

Email address of contact person*