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Particular Hazardous Work Notification Form

Use this form to notify WorkSafe New Zealand of Particular Hazardous Work as required under Regulation 26 of the Health and Safety in Employment Regulations (1995).

You must provide WorkSafe New Zealand with 24 hours notice of work that is particularly hazardous.

If you want to notify WorkSafe New Zealand of the death of a person, injury/illness sustained by someone or a workplace incident that exposed someone to serious risk, please click on the following link: http://forms.worksafe.govt.nz/notifiable-event-notification

Fields marked with an * are required

NATURE OF PARTICULAR HAZARDOUS WORK (Tick all that apply):

Construction work with a risk of falling 5 metres or more (see exclusions below)

Exclusions:

work in connection with a residential building up to and including 2 full storeys
work on overhead telecommunications lines and overhead electric power lines
work carried out from ladder only
maintenance and repair work of a minor or routine nature.

Erecting or dismantling scaffolding with a risk of falling 5 metres or more
Logging or tree felling undertaken for commercial purposes
Use of a lifting appliance where the appliance has to lift a mass of 500 kilogrammes or more a vertical distance of 5 metres or more (see exclusions below)

Exclusions:

work using an excavator
work using a forklift, or
work using a self-propelled mobile crane

Work in any drive, excavation, or heading in which any person is required to work with a ground cover overhead
Work in any excavation in which any face has a vertical height of more than 5 metres and an average slope steeper than a ratio of 1 horizontal to 2 vertical
Work in any pit, shaft, trench, or other excavation in which any person is required to work in a space more than 1.5 metres deep and having a depth greater than the horizontal width at the top
Work involving the use of explosives, or storage of explosives for use at the worksite
Work in which a person breathes compressed air, or a respiratory medium other than air (diving)
Work in which a person breathes compressed air, or a respiratory medium other than air (not diving)

Description of work *

LOCATION OF WORK:

Worksite address 1 *
Worksite address 2
Suburb *
City *

Main access road

Location
Provide directions on access as needed.

CONTROL OF WORK:

What is the status of your business in relation to this work? * PCBU (engaging other PCBU to do the work)
PCBU (using own workers)
Contractor
Sub-contractor

Business name *

Industry

NZ business number

Street address 1 *
Street address 2
Suburb *
City *

Contact name *

Phone *

Fax

Email address *

Intended start date *

Expected completion date *

Date created

Local office *

CERTIFICATE OF COMPETENCE:

Certificate holder

Certificate number

Phone

Fax

Expiry date