SHE REPRESENTATIVE NOMINATION FORM

DOC NO CLIENT EFFECTIVE DATE REV DATE REV APPROVED BY

PROC/SHEREPNF/01 ESKOM 17/01/2024 17/01/2025 00 FRANKLIN NGOVE

PROJECT DESCRIPTION REFURBISHMENT OF 8MM HDPE EQUIPMENT DOSING LINE THROUGH

REMOVAL AND REPLACEMENT OF THE DEFECTIVE LINES
PROJECT LOCATION KUSILE POWER STATION
KEY OHS PERONNEL NAME CONTACT DETAILS SIGNATURE SIGNATURE DATE
SECTION 16(2)
SITE MANAGER
DOCUMENT ORIGINATOR ACE MABANDLA 076 041 7671 17/01/2024

Occupational Health and Safety Act No 85 of 1993 as Amended

SHE REP NOMINATION FORM

PROJECT NAME:
____________________________________________________________________

DATE: ________________________________
1. ____________________________________________________________

2. ____________________________________________________________

3. ___________________________________________________________

4. ___________________________________________________________

5. __________________________________________________________

6. __________________________________________________________

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Kindly note that the appointment of a health and safety representative is a serious contribution
to the health and safety system within the company. It is for this reason that when making a
nomination it is vitally important that you ensure that the person who is nominated will be
competent to carry out the tasks required of a health and safety representative and that such
person will be committed to the position.
Note also, that the person nominated must be a full time employee and must be familiar with the
area for which he or she is nominated.
PLEASE ENSURE THAT YOU PRINT THE NAME OF YOUR NOMINEE CLEARLY
TOGETHER WITH THE INITIALS OF THE INDIVIDUAL NOMINATED

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