HSE-PRO-010a JCU HSR Nomination Form
Version: 1 Approval Date: 27/6/2016 Next Review Date: 27/6/2018 Page 1 of 1
I
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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