I have been duly elected as a Health and Safety Representative (HSR) for my work group.

I understand that my tenure for the position must be relinquished if the following occurs:

• Expiration of a 3-year period (this does not preclude renomination for the position)
• Upon my written resignation from the position
• If I cease to be a worker in the work group I have been elected to represent
• In accordance with Work Health & Safety Regulations, I am removed from the position by a majority of members of the work group
• If I undertake an action described in Section 65 of the Regulations which results in disqualification to perform the role

I declare that I accept the position of the Health & Safety Representative for the above-named Work Group and understand the roles and responsibilities associated as outlined below.

• Represent the workers in the work group on issues related to work health and safety
• Undertake inspections of the workplace
• Report hazards, near misses and incidents, and consult and suggest solutions to reduce risks associated
• Consult with workers and managers in the work group on matters about health and safety
• Refer matters for discussion at the Health and Safety Committee (HSC) meeting
• Assist with investigations following workplace incidents and near miss events
• Maintain currency with health and safety legislation and information
• Participate as required in the Health and Safety Committee