Template

240-43921804 Rev 5
Identifier
Document
Zero Harm 240-53463684 Rev 2
Identifier
Nomination Form Effective Date Mar 2019
Review Date Jan 2022

The nomination form is to be completed and signed prior to being submitted.

NOMINATION: DIVISIONAL AWARD/ ESKOM AWARD

Zero Harm

Definition: Participation in local and external initiatives / work groups,

which have a significant impact on the health, safety and
environment of individuals or groups and that enhances and
continuously improve Eskom’s business efficiency and image.

NOMINEE(S) - Individual and or teams

In cases where a team is nominated, please fill in the leader’s details below and attach a list of names,
designation, unique number and telephone number for each team member

First Name and Surname of Nominee/ Team Leader: _______________________________

Unique Number: ___________ Band: ________ Telephone Number____________________

Designation: _____________________________________________

Business Unit:- ___________________________________________

Division:- ________________________________________________

NOMINATOR

First Name and Surname of Nominator: ________________________________________

Unique Number: ___________ Band: ________________ Telephone Number______________

Designation: _____________________________________________

Business Unit:- ___________________________________________

Division:- _____________________________ Signature: ___________________________

Nominees Manager: ______________________________ Unique Number: ____________

Signature: ____________________________________ Date: ________________________

APPROVED BY LINE MANAGER

First Name and Surname:- _______________________________________________________

Division:- ________________________________________________

Signature: ____________________________________ Date: __________________________

Public
When downloaded from the document management system, this document is uncontrolled and the responsibility rests with
the user to ensure it is in line with the authorised version on the system.

Page 1 of 3
 Template
240-43921804 Rev 5
Identifier
Document
Zero Harm 240-53463684 Rev 2
Identifier
Nomination Form Effective Date Mar 2019
Review Date Jan 2022

MOTIVATION FOR NOMINATION – Zero Harm

In completing the motivation it is advisable to “state the problem, solution, results and benefits” where
possible. Please attach any documentation in support of the nomination that need to be considered in the
evaluation. The following is criteria that will be used to evaluate the nomination and should be considered
when crafting the motivation:

1. Initiate and ensure a safe and healthy working environment for employees. Our customers,
suppliers and people of the country
2. Involved in a particular event where an action resulted in preventing an incident or preventing
injuries as a result of an incident or rescue and save a life
3. Participation in local and external initiatives / work groups, which have a significant impact on the
health, safety and environment of individuals or groups and that enhance Eskom as a business
4. Demonstrate outstanding leadership in health, safety and environment

MOTIVATION FOR NOMINATION

What was the problem/situation /task?

What is the solution/action taken?

Public
When downloaded from the document management system, this document is uncontrolled and the responsibility rests with
the user to ensure it is in line with the authorised version on the system.

Page 2 of 3
 Template
240-43921804 Rev 5
Identifier
Document
Zero Harm 240-53463684 Rev 2
Identifier
Nomination Form Effective Date Mar 2019
Review Date Jan 2022

What is the outcome/results /benefits of the task?

ANNEXURE A: TEAM TEMPLATE

Please complete the template below if a team is nominated

Unique No Name Surname

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Public
When downloaded from the document management system, this document is uncontrolled and the responsibility rests with
the user to ensure it is in line with the authorised version on the system.

Page 3 of 3