ACC Workplace Safety Management Practices application form

ACC 4028 ACC Workplace Safety Management Practices application form Email your completed application form and supporting documents to wsmp@acc.co.nz or post to: ACC Workplace Safety Management Practices, PO Box 242, Wellington 6140. Further information to help you complete this application form is available on pages 6 and 7. Section 1 Application type Please tick one option below to indicate which type of application this is. Single business/employer A business/employer with one legal name. This business may have several ACC numbers (this is from payroll details that you have previously supplied to Inland Revenue). Trusts, incorporated societies, shareholders, partnerships and joint ventures must be also included here and can t form part of a group. Group of companies This is a group of limited liability companies that consist of a parent company and its subsidiaries. We require written confirmation that companies included in this section are subsidiary companies (see definition on page 9) as defined under the Companies Act 1993. All subsidiary companies applying must be 51% or more owned by the parent company and operate a common health and safety system. Section 2 Contact details Please provide details for someone we can contact if we need further information about this application. Name of contact person First name Surname Job title/position Contact phone numbers Area code Number (work) Code Number (mobile) Email address Section 3 Business details The business/employer name(s) on this application must be the same as the information ACC holds (this will be on your ACC invoice). Your business/employer name information is provided to ACC by Inland Revenue. If this is incorrect, you need to amend the details with Inland Revenue. Name of business/ employer (Parent company s name is required for Group of companies applications) Address for correspondence Street address or PO box number Suburb City and post code ACC number(s) information Single business/employer Please list all the ACC number(s) for this business/employer. Group of companies application Please list all company names and ACC number(s) on next page. 1 December 2015

Group of companies The legal name of each company is required and all the ACC number(s) associated to each company must be listed. Please use a separate sheet of paper if you have more companies. 2

Section 4 Worksite details location of your business(es) Please provide details of all the worksites that the business operates from. The number of employees must be separated per activity, per worksite, and per ACC number. Please complete a separate list if you need to add more information. ACC number(s) that relate to each worksite Physical address of business There must be at least one physical address provided (e.g. an office). If you have external sites that are long-term or permanent please list these as per example 1. If you have external sites that are temporary please list these as per example 2. Business activity Number of employees Full-time Part-time Casual Seasonal Example 1 A4886166E Example 1 134 High Street, Timaru Administration Engineering 2 2 1 Example 2 A2501158E Example 2 148 High Street, Timaru Administration Plumbing and drainage 6 10 3

Section 5 Workplace health and safety questions Please answer all the questions below. These questions apply to all businesses/employers listed on this application. 1. I understand what a notifiable injury or illness, or death of a person is and have ensured these incidents, if any, have been recorded in the incident register. Yes No N/A 2. I have reported all notifiable injury or illness, or death of a person incidents to WorkSafe New Zealand or the appropriate agency. 3. In the last two years the business(es) named has had (number of) notifiable injury or illness, or death of a person incident(s). 4. In the last two years the business(es) named has had (number of) health and safety prosecution(s) or improvement notices (all notices must be attached to this application). Section 6 ACC-approved auditor selection The Workplace Safety Management Practices workplace audit will be conducted by an ACC-approved auditor. The auditor may be given information regarding your businesses/companies claims history as part of the workplace audit. Please tick one option below to indicate your preference for an ACC staff auditor or an ACC-approved external auditor. OPTION ONE ACC staff auditor Please provide the contact details of the person who the auditor can contact for the audit. Please tick if this is the same contact person (as on page 1) for this application. Name of contact person First name Surname Job title/position Contact phone numbers Area code Number (work) Code Number (mobile) Email address Proposed audit date (if known) Day Month Year OPTION TWO ACC external auditor Please note: ACC external auditors are not funded by ACC. In selecting an external auditor you agree to pay for the full cost of the audit. The auditor must see your confirmation of audit letter prior to conducting the audit. For a list of ACC-approved external auditors please refer to www.acc.co.nz/approvedauditors Name of auditor Proposed audit date (if known) Day Month Year 4

Section 7 Senior Management declaration Please tick all boxes below and complete the Senior Management details (see page 9 for definition). On behalf of all the businesses/employers named in this application, I declare and confirm that: I meet the criteria of Senior Management and have the authority to act on behalf of each business/employer named. I understand my legal obligations as an employer under the Health & Safety at Work Act 2015. I authorise the contact person supplied on this application form to discuss the application and any related information on behalf of each business/employer named. A thorough self-assessment of all our business worksites has been completed and I believe all our workplace safety management practices will meet at least the Primary level entry requirements. The worksite(s) and ACC number(s) listed in this application use a common health and safety system practising the same standards of workplace safety. Only the ACC number(s) listed will be eligible to receive the discount. All the information provided is complete and accurate and we will notify ACC if any of the information supplied should be updated to reflect any changes in the businesses/employers applying for the discount, prior to the audit being undertaken. I understand that ACC will review and consider the past two years ACC claims history relating to the businesses/ employers named as part of this application. ACC is authorised to give this information to the ACC-approved auditor. I understand that the information ACC collects on this form will be used in accordance with the requirements under the Accident Compensation Act 2001, the Privacy Act 1993 and the Official Information Act 1982. ACC will at all times comply with the guidelines of those Acts. Name First name Surname Job title/position Signature Date Day Month Year Section 8 Checklist When completing your application please ensure the following information or documents are included or attached. The number of the employees for each company broken down to show which employees undertake which work activities, at each location and under what payroll (ACC number). A full list of all workplace health and safety prosecutions or improvement notices in the last two years together with details of any relevant corrective action undertaken. A full copy of all reports(s) of any investigation into each notifiable injury or illness, or death of a person incident(s), together with any corrective action recommended and implemented and a full copy of WorkSafe New Zealand or appropriate agency feedback or document for each incident. Privacy Whenever you provide ACC with business or personal information, we will keep that information secure. We will only use the information you provide in relation to your cover, levies or claims. If you have supplied one or more contact people on this form, we may contact them to seek further information in relation to your application. By signing the declaration above you are agreeing to us contacting those people and discussing your ACC account. You can check the information we hold about you or your business at any time by contacting our business helpline on 0800 222 776 or via email at wsmp@acc.co.nz 5

Information to help complete this application form Application type Single business/employer Means a single employer, business, company, organisation, trust, incorporated society, shareholder, partnership or joint venture is applying. Group of companies This is for limited liability companies where each company is a subsidiary of the same parent company. All subsidiary companies applying must be 51% or more owned by the parent company and operate a common health and safety system. Example of Group ABC Ltd BCD Ltd 100% owned by ABC Ltd CDE Ltd 50% owned by ABC Ltd DEC Ltd 70% owned by ABC Ltd If you need more help or to see whether you can do a group of companies application, please contact ACC on 0800 222 776 or email wsmp@acc.co.nz Contact details This is someone who we can contact if we need further information about your application. They have overall responsibility of the Workplace Safety Management Practices performance and will provide information in regards to this application. Business details The business/employer name(s) on the application must be the same as the information ACC has. This will be on your ACC invoice. Group of companies Each company must: be named in the application. Additional companies cannot be added/included to the application once it is accepted supply all ACC numbers associated to the company or business named be a limited liability company be a subsidiary of the parent company named in this application with more than 51% ownership. Worksite details location of your business(es) To be able to process your application we need you to let us know the: location and physical address of your business the total number of employees per worksite and the ACC number. This includes part-time, casual and seasonal workers at the time of application the total number of employees. This should match your payroll total PAYE (excluding contractors paid by scheduler payment/withholding payments). 6

Name of organisation: Branch/department: 1. Particulars of Accident Date of Accident: DD / MM / YEAR Time: Location: Date Reported: DD / MM / YEAR 2. The Injured Person Name: Address: Date of Birth: DD / MM / YEAR Phone Number: Length of employment at plant: on job: Type of Injury: Bruising Dislocation Strain/sprain Scratch/abrasion Internal Fracture Amputation Foreign body Laceration/cut Burn/scald Chemical reaction Other (specify) Injured part of body: Comments: 3. Damaged Property Property or material damaged: WORKSAFE NEW ZEALAND PO Box 165, Wellington 6140 0800 030 040 www.worksafe.govt.nz Nature of damage: Object/substance causing damage: 4. The Accident Description: Describe what happened. If this was a vehicle accident, add a drawing of the accident scene on the other side of this page. Analysis: What caused the accident? How serious could it have been? Minor Serious Very serious How often is this likely to happen again? Not often Occasionally Often 1. Particulars of employer, self-employed person or principal: (business name, postal address and telephone number) 2. The person reporting is: an employer a principal a self-employed person 3. Location of place of work: (shop, shed, unit nos., oor, building, street nos. and names, locality/suburb, or details of vehicle, ship or aircraft) 4. Personal data of injured person: Name: Residential address: Date of birth: DD / MM / YEA R Sex: (M/ F) 5. Occupation or job title of injured person: (employees and self-employed persons only) 6. The injured person is: an employer self other a contractor (self-employed person) 7. Period of employment of injured person: (employees only) 1st w e e k 1st month 1-6 months 6 months-1 year 1-5 years over 5 years non-employee 8. Treatment of injury: none rst aid only doctor but no hospitalisation 9. Time and date of accident/ serious harm: WORKSAFE NEW ZEALAND Email: seriousharm.noti cation@worksafe.govt.nz Fax: 0 9 984 4115 Phone: 0800 030 040 Post: The Registrar, WorkSafe NZ, PO Box 10 5-146, Auckland 1143 hospitalisation Time: (am/pm) Date: DD / MM / YEAR Shift : day afternoon night Hours worked since arrival at work: (employees and self-employed persons only) 10. Mechanism of accident/ serious harm: fall, trip or slip heat, radiation or energy hitting objects with part of the body biological factors sound or pressure chemicals or other substances ment al stress being hit by moving objects body st ressing 11. Agency of accident/ serious harm: machinery or (mainly) xed plant mobile plant or transport powered equipment, tool, or appliance non-powered handtool, appliance, or equipment chemical or chemical product m aterial or subst ance environmental exposure (eg dust, gas) animal, human or biological agency (other than bacteria or virus) bacteria or virus Workplace health and safety questions It is important that you understand your obligations under the Health & Safety at Work Act 2015. Your ACC claims will be reviewed as part of the application process. All notifiable injury or illness, or death of a person incidents must be: recorded in the your incident register or similar document and notified to WorkSafe New Zealand (or other appropriate agency). If you have had any notifiable injury or illness, or death of a person incidents you will need to provide copies of the following documents and any written response from WorkSafe New Zealand (or appropriate agency) for each incident. ACCIDENT INVESTIGATION FORM FORM OF REGISTER OR NOTIFICATION OF CIRCUMSTANCES OF ACCIDENT OR SERIOUS HARM Required for section 25(1), (1A), (1B), and (3)(b) of t he Health and Safety in Employment Act 1992. For non-injury accident, complete questions 1, 2, 3, 9, 10, 11, 14 and 15 as applicable. WSNZ_1218_MAY 15 WSNZ_00002.6_FEB 14 For more information www.business.govt.nz/worksafe ACC-approved auditor selection ACC staff auditor Let us know a suitable timeframe for your audit. When considering your preferred audit timeframe, please allow six to eight weeks after we have received your application. ACC-approved external auditor You will need to arrange the audit and the associated cost directly with the auditor you have chosen. ACC does not regulate the cost of external auditors so please be aware charges may vary. For a list of ACC-approved external auditors please refer to www.acc.co.nz/approvedauditors Once your application is accepted ACC will send you an accepted letter for you to give to the auditor. The audit date should not be set until your application is accepted. If your preferred audit date is more than eight weeks from when you applied, you will be contacted a month prior to the audit to confirm that the information supplied in your application is still current and correct. Please note: You must provide the auditor with a copy of ACC s acceptance letter prior to the audit. If the audit is completed before ACC has accepted your application ACC is unable to accept the auditor s audit report. Senior Management declaration The declaration must be completed by a senior management representative who confirms that the details are correct. All boxes must be ticked otherwise the application can not be accepted. More Information For more information contact us on 0800 222 776, email wsmp@acc.co.nz or visit www.acc.co.nz/wsmp 7

Definitions Appropriate Agency Maritime Safety Authority, NZ Transport Agency, New Zealand Police, Civil Aviation Authority of New Zealand. Audit tool/self-assessment This is the Workplace Safety Management Practices Audit Standard ACC442 Measuring your capabilities in Workplace Safety Management. Notifiable event The Health and Safety at Work Act 2015 definition of 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. Notifiable injury or illness (1) The Health and Safety at Work Act 2015 defines a notifiable injury or illness, in relation to a person, means (a) any of the following injuries or illnesses that require the person to have immediate treatment (other than first aid): (i) the amputation of any part of his or her body: (ii) a serious head injury: (iii) a serious eye injury: (iv) a serious burn: (v) the separation of his or her skin from an underlying tissue (such as degloving or scalping): (vi) a spinal injury: (vii) the loss of a bodily function: (viii) serious lacerations: (b) an injury or illness that requires, or would usually require, the person to be admitted to a hospital for immediate treatment: (c) an injury or illness that requires, or would usually require, the person to have medical treatment within 48 hours of exposure to a substance: (d) any serious infection (including occupational zoonoses) to which the carrying out of work is a significant contributing factor, including any infection that is attributable to carrying out work (i) with micro-organisms; or (ii) that involves providing treatment or care to a person; or (iii) that involves contact with human blood or bodily substances; or (iv) that involves handling or contact with animals, animal hides, animal skins, animal wool or hair, animal carcasses, or animal waste products; or (v) that involves handling or contact with fish or marine mammals: (e) any other injury or illness declared by regulations to be a notifiable injury or illness for the purposes of this section. (2) Despite subsection (1), notifiable injury or illness does not include any injury or illness declared by regulations not to be a notifiable injury or illness for the purposes of this Act. (3) In this section, animal has the same meaning as in section 2(1) of the Animal Welfare Act 1999 fish has the same meaning as in section 2(1) of the Fisheries Act 1996 marine mammal has the same meaning as in section 2(1) of the Marine Mammals Protection Act 1978. Senior Management The management level within a business or organisation that reports directly to the most senior manager (e.g. CEO or board), and has the authority to make resources available for health and safety management. This description may also include the next tier of managers in a large multi-site organisation. 8

Serious harm definition Serious harm means: (1) death, (2) or any of the following conditions that amounts to or results in permanent loss of bodily function, or temporary severe loss of bodily function: respiratory disease, noise-induced hearing loss, neurological disease, cancer, dermatological disease, communicable disease, musculoskeletal disease, illness caused by exposure to infected material, decompression sickness, poisoning, vision impairment, chemical or hot-metal burn of eye, penetrating wound of eye, bone fracture, laceration, crushing. (3) Amputation of body part. (4) Burns requiring referral to a specialist registered medical practitioner or specialist outpatient clinic. (5) Loss of consciousness from lack of oxygen. (6) Loss of consciousness, or acute illness requiring treatment by a registered medical practitioner, from absorption, inhalation or ingestion of any substance. (7) Any harm that causes the person harmed to be hospitalised for a period of 48 hours or more commencing within seven days of the harm s occurrence. Subsidiary A subsidiary as defined by the Companies Act 1993 (1) For the purposes of this Act, a company is a subsidiary of another company if, but only if, (a) that other company (i) controls the composition of the board of the company; or (ii) is in a position to exercise, or control the exercise of, more than one-half the maximum number of votes that can be exercised at a meeting of the company; or (iii) holds more than one-half of the issued shares of the company, other than shares that carry no right to participate beyond a specified amount in a distribution of either profits or capital; or (iv) is entitled to receive more than one-half of every dividend paid on shares issued by the company, other than shares that carry no right to participate beyond a specified amount in a distribution of either profits or capital; (b) the company is a subsidiary of a company that is that other company s subsidiary (2) For the purposes of this Act, a company is another company s holding company, if, but only if the other company is its subsidiary. 9