Safety and Health Representative of the Year

Award for excellence SHR Award Nomination Form

This award recognises the outstanding accomplishments of our Safety & Health Representatives (SHR’s). Nominations for the award may be submitted to Health and Safety by Curtin staff using the form below. Please refer to the “Information” section on page 3 of this document.

The deadline for nominations is the 12 November 2019.

Date: _____/_____/2019

Nominee Name (s): ____________________________________________________

Nominated by: ____________________________________________________

Tick relevant Award Category

Tick Award Category CriteriaAchievement Developed and/or implemented a successful innovation or

safety improvement to the workplace.

Functions To what extent does the Safety and Health Representative fulfil their responsibilities under the Occupational Safety and Health Act? Inspecting the workplace for hazards at times outlined

by the employer. Reporting all hazards to the supervisor of the area. In consultation with supervisors, investigating any

reported incident or hazard. Keeping informed about current safety and health

issues, policies and procedures in the organisation and safety and health matters in general.

Promoting safe work procedures and safety and health to co-workers.

Participating in, and contributing to, safety and health

Version 3 Uncontrolled document when printed

Tick Award Category Criteriatraining programs and initiatives.

Attending relevant and approved training courses and refresher courses on safety and health.

Communication Demonstrates excellent communication and consultation in the workplace.

Engagement & Commitment

Attend and actively participate in H&S Committees at the University.

Please use the space below to describe your reasons for this nomination. Be as detailed as possible and attach any other reference documentation if relevant: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Internal use only

Version 3 Uncontrolled document when printed

Nomination received on (Date): _____________________________________

Assessed by: _____________________________________

Assessment Date: _____________________________________

InformationAboutHealth and Safety would like to recognise and reward special effort and achievement by a Safety and Health Representative through a recognition program. Nominations are to be submitted with an award to be issued to an individual based on specific criteria with the award being issued on an annual basis.

Eligibility The program is open to all SHR’s as an individual nomination. Nominations must meet specific criteria as outlined in “Nominations”. Nominations will be assessed based on merit and application of the Curtin Values.

NominationsNominations can be made by any of the following people: Co-worker(s) - Direct line manager - Non-direct line manager. Nominations must be made via the nomination form addressing the required criteria.Nominations can be made by emailing the nomination form to healthandsafety@curtin.edu.au

Rewards and recognitionRewards and Recognition will be processed on an annual basis. The winner will be announced at the end of year Safety & Health Representative and Incident Response Network meeting (or similar). Awards will be judged and voted by Health and Safety staff.

Recipients receive: 1. A voucher or prize as approved by the Director Health and Safety or delegate2. A certificate of recognition signed by the Director Health and Safety or delegate outlining the award

Disputes and Discrepancies Judges decisions are final. No disputes will be entered into.

Version 3 Uncontrolled document when printed