SHE REPRESENTATIVE ELECTION FORM

DOC NO CLIENT EFFECTIVE DATE REV DATE REV APPROVED BY

PROC/SHEREPEF/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 REPRESENTATIVE ELECTION FORM
PROJECT NAME:
________________________________________________________________

DATE: ________________________________________________________________

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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 careful consideration must be given
when electing the health and safety representative. Ensure that the
person you elect is in your mind the most competent person for the
task.
PLEASE ENSURE THAT YOU MARK ONLY ONE NAME WITH AN X. THE MARKING
OF MORE THAN ONE NAME WILL RESULT IN A SPOILT PAPER.

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