Health and Safety Rep form

Please complete the online registration form if you have been elected as a Health and Safety Rep.

Are you an elected Health & Safety Rep as noted in the HSE Act?

Personal details


Residential contact details

Employer details

Contact details of person who approves leave (e.g. HR Manager)

Industry Information


Please select your preferred method of contact

Privacy statement

This registration information will be used:
1. To randomly survey participants to seek feedback on training programmes (individuals will not be identified in any published survey results)
2. To prepare general management and statistical reports on the WorkSafe Reps training programme for the NZCTU, ACC and the individual union identified above - for the purposes of managing the WorkSafe Reps programme.