The Safety Declaration Form is a crucial document used in New Zealand workplaces to ensure compliance with the Health and Safety at Work Act 2015 and associated regulations. This form is typically required at the commencement of employment or contractor engagement, when workers undertake new roles, or when significant changes occur in workplace safety procedures. The document serves as both a legal record and an educational tool, ensuring workers understand their safety obligations and workplace-specific hazards. It includes acknowledgments of safety training, emergency procedures, PPE requirements, and incident reporting protocols. The form helps organizations demonstrate due diligence in safety management while protecting both workers and employers under New Zealand law.
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1. Personal Information: Declaration of individual's full name, position, and contact details
2. Health and Safety Acknowledgment: General acknowledgment of understanding workplace health and safety obligations under NZ law
3. Safety Training Confirmation: Confirmation of completed safety inductions and required training
4. Incident Reporting Agreement: Commitment to report all accidents, incidents, and near-misses
5. PPE Compliance: Agreement to use required Personal Protective Equipment
6. Emergency Procedures: Confirmation of understanding emergency and evacuation procedures
7. Declaration Statement: Formal statement confirming all information is true and accurate
8. Signature Block: Space for signature, date, and witness details if required
1. Medical Conditions: Optional disclosure of relevant medical conditions that could affect safety at work
2. Hazardous Substances Handling: For workplaces involving hazardous substances, specific acknowledgments of related procedures
3. Vehicle Operation: For roles involving vehicle operation, specific safety commitments related to vehicle use
4. Working at Heights: For roles involving working at heights, specific safety acknowledgments
5. Confined Spaces: For roles involving confined space work, specific safety acknowledgments
6. Remote/Lone Working: For roles involving remote or lone working, specific safety protocols
1. Schedule A - Site-Specific Hazards: List of specific hazards relevant to the workplace or site
2. Schedule B - Emergency Contact Information: List of emergency contacts and procedures
3. Schedule C - PPE Requirements: Detailed list of required PPE for specific tasks or areas
4. Appendix 1 - Incident Reporting Procedure: Detailed procedure for reporting incidents and near-misses
5. Appendix 2 - Risk Assessment Matrix: Standard risk assessment matrix for reference
Relevant legal definitions
Accident
Company
Competent Person
Contractor
Emergency
Employee
Employer
Hazard
Hazardous Substance
Health and Safety Representative
Incident
Near Miss
Notifiable Event
PCBU (Person Conducting a Business
PPE (Personal Protective Equipment)
Reasonably Practicable
Risk
Safe Work Procedure
Safety Data Sheet
Site
Supervisor
Worker
Workplace
Work Area
Safety Officer
Training Record
Safety Equipment
Emergency Procedure
Safety Protocol
Incident Report
Company
Competent Person
Contractor
Emergency
Employee
Employer
Hazard
Hazardous Substance
Health and Safety Representative
Incident
Near Miss
Notifiable Event
PCBU (Person Conducting a Business
PPE (Personal Protective Equipment)
Reasonably Practicable
Risk
Safe Work Procedure
Safety Data Sheet
Site
Supervisor
Worker
Workplace
Work Area
Safety Officer
Training Record
Safety Equipment
Emergency Procedure
Safety Protocol
Incident Report
Clauses
Personal Information
General Safety Acknowledgment
Risk Awareness
Safety Training
Emergency Procedures
PPE Requirements
Incident Reporting
Hazard Identification
Medical Disclosure
Safety Equipment
Workplace Rules
Vehicle Safety
Chemical Safety
Working at Heights
Manual Handling
Employee Responsibilities
Declaration
Certification
Witness
General Safety Acknowledgment
Risk Awareness
Safety Training
Emergency Procedures
PPE Requirements
Incident Reporting
Hazard Identification
Medical Disclosure
Safety Equipment
Workplace Rules
Vehicle Safety
Chemical Safety
Working at Heights
Manual Handling
Employee Responsibilities
Declaration
Certification
Witness
Relevant Industries
Construction
Manufacturing
Mining
Healthcare
Agriculture
Forestry
Transportation
Warehousing
Energy
Chemical Processing
Marine Operations
Aviation
Infrastructure
Waste Management
Food Production
Retail
Hospitality
Relevant Teams
Health and Safety
Operations
Maintenance
Production
Logistics
Facilities Management
Quality Assurance
Engineering
Field Services
Security
Cleaning Services
Food Services
Manufacturing
Warehouse Operations
Human Resources
Relevant Roles
Site Manager
Construction Worker
Machine Operator
Warehouse Staff
Factory Worker
Maintenance Technician
Field Service Engineer
Healthcare Worker
Laboratory Technician
Truck Driver
Forklift Operator
Safety Inspector
Production Supervisor
Farm Worker
Mining Engineer
Electrician
Plumber
Chef
Security Guard
Cleaner
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