Occupational Health and Safety Nomination/Appointment form

Please complete this form if you would like to nominate for a safety or environmental position in your zone.

Form fields marked with an asterisk (*) are mandatory

First name:
Surname:
Email address: *
Department/School/Unit:
Faculty/Division:
Campus:
Phone number:
Occupational health and safety zone to which you belong: List of OHS&E zones
I would like to nominate myself as one of the following:	Safety Officer Deputy Safety Officer Zone OHS&E Chair Radiation Safety Officer Deputy Radiation Safety Officer Environmental Officer First Aid Co-ordinator Biosafety Officer Laser Safety Officer
Specify areas (ie departments/divisions) which you will be covering:
NOTE: For all Health & Safety Representative nominations, please refer to the Health and safety representative/ deputy health and safety representative nomination form (MS Word)
Approval by my Head of Department/Unit/Supervisor:
Authorised by (Name): *
Authoriser's telephone:
Declaration (please tick): *	My supervisor has approved the above nomination