Health and safety rep appointment form S17

risk reps functions comittee photoSA Employers are required to formalise health and safety rep appointments, using the format prescribed by the SA OHS Act in Section 17 and 18.

Company name ,,,,,,,,,,,,,,,,,, Health and Safety Representative appointment, in terms of the Occupational Health and Safety Act, Section 17

Appointee’s full name ,,,,,,,,,,,,,,,,,,,,,,,,,,,,

I, (appointer’s full name) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,
as (title and legal appointment) ,,,,,,,,,,,,,,,,,
of (group, department, division) ,,,,,,,,,,,,,,,,
hereby appoint (appointee),,,,,,,,,,,,,,,,,,,
as Health and Safety Representative for (area) ,,,,,,,,,,,,,,,,,,,,,

In terms of Section 18, your functions are;
1) Represent your employee electorate’s interests in terms of occupational health and safety.
2) Carry out health and safety inspections of your workplace as designated above, prior to health and safety committee meetings.
3) Serve on the relevant health and safety committee.
4) Inform your supervisor any deviations regarding health and safety that come to your attention.

You may also be required and entitled to:
1) visit incident sites and attend inspections
2) attend incident investigations or formal inquiries
3) inspect relevant document, excluding personal medical files
4) accompany state inspectors
5) be accompanied by a technical advisor as approved by employer
6) participate in internal audits.

The committee determines dates and times of health and safety meetings.

You will be required to undergo Health and Safety Representative training as scheduled.

Your appointment is valid from (date) ,,,,,,,,,,,,, to (date) ,,,,,,,,,,,,,,
Appointer (signature) ,,,,,,,,,,,,,,,,,,,,,,,,,,

ACCEPTANCE

I, (appointee’s full name) ,,,,,,,,,,,,,,,,,,,,,,,,,,
understand the implications of the appointment as detailed above, and confirm my acceptance.
Signature ,,,,,,,,,,,,,,,,, ; Date ,,,,,,,,,,

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