HSE-PRO-010a JCU HSR Nomination Form
Version: 1 Approval Date: 27/6/2016 Next Review Date: 27/6/2018 Page 1 of 1
insert name hereby nominate for the
position as the Health and Safety Representative for
insert work group name (if applicable)
Please use the space below to detail the experience and / or skills you could bring to the role
Signature of nominee Date
Nomination Checklist (to be completed by Nominee)
I can confirm that I meet the eligibility criteria
I have discussed my intention to nominate as a HSR with my immediate Supervisor
Email this form to safety@jcu.edu.au
This section to be completed by HSE Unit
Name of HSE representative processing nomination
HSR nominee list is updated for the election process (if applicable)
Correspondence is provided to nominee outlining the outcome of the election (if applicable)
Training complete
Eligible for payment of Allowance (insert electronic Signature)
Notified HR for commencement of allowance
Notify Workplace Health and Safety Queensland of appointments
Save completed form in TRIM
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