HSE-PRO-010b JCU HSR Resignation Form
Version: 1 Approval Date: 27/6/2016 Next Review Date: 27/6/2018 Page 1 of 1
insert name hereby formally resign
from my position as the Health and Safety Representative for
insert work group name
insert date
The reason for my resignation is:
No longer employed by / within the work group for which I was elected
Resigned from JCU
Other (please provide details below)
Signature of HSR Date
Handover Checklist (to be completed by resigning HSR)
Clear contact details from any internal documentation e.g. posters, Division / Directorate / College website
Incident investigations / workplace inspections - finalise or handover any outstanding items
Formally notify work group of resignation
Email this form to safety@jcu.edu.au
This section to be completed by HSE Unit
Name of HSE representative processing resignation
Update HSR list
Updated HSR list published to HSE website and forwarded to WHSQ
Formal invitation for HSR nominations to work group (if applicable)
Save completed form in TRIM
click to sign
click to edit
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