Appointment: Health And Safety Representative Form printable pdf download

Appointment: Health And Safety Representative Form

APPOINTMENT: HEALTH AND SAFETY REPRESENTATIVE

Section 17 of the Occupational Health and Safety Act(Act 85 of 1993)

I, …………………………………………………..having been appointed under Section 16(2) of the

OHS Act as …………………………………for …………………………………………..

Hereby appoint you …………………………………………..as a Health and Safety Representative for/

of………………………………………….

The following will be your duties and responsibilities:

1) To carry out monthly inspections of ______________________ (designated workplace)

2) To serve on the ________________________ Health and Safety Committee

3) Inspections are to be carried out on the _______________________ (eg 1

Monday ) of every

month between the hours of ______________ and _____________

4) Other functions agreed upon are:

i) __________________________

ii) ___________________________

iii) ___________________________

5) Meetings of the ___________________________________ Health and Safety Committee

6) Will be held at (time) _______________ on the ____________________(e.g. Last Friday on every

month).

Position valid from ………………………………. Until ………………………………………..

Area of responsibility ………………………………………………………………………………

Person to report to …………………………………………………………..

______________________________

_________________________---

Signature of Manager

Date

Please confirm your acceptance of this appointment by completing the following:

ACCEPTANCE

I, ………………………………………………………..

Understand the implications of this appointment as detailed above and confirm my acceptance.

………………………………………………

………………………….

Signature

Date

Appointment: Health And Safety Representative Form