Health & Safety Committee Member Nomination Form

NOMINEE

Name
Department		Title
Email		Number

NOMINATOR

Name
Department		Title
Email		Number

REASON FOR NOMINATION

Please describe why you are nominating this individual for the Health & Safety Committee, highlighting their qualifications, experiences, or traits that make them a suitable candidate (max 300 words).

NOMINEE’S EXPERIENCE IN HEALTH & SAFETY

Detail any relevant experience, training, or certifications the nominee has in health and safety.

CONTRIBUTIONS TO WORKPLACE SAFETY

Describe any specific contributions the nominee has made to improve workplace safety within the organization.

ENDORSEMENT

Name
Department
Contact

NOMINEE CONSENT

Has the nominee consented to this nomination?

• Yes

• No

Nominee’s Signature:___________________ 

NOMINATOR DECLARATION

I hereby declare that the information provided in this form is accurate and complete, to the best of my knowledge.

Nominator’s Signature:_______________________ 

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