WorkSafe Representative Details

* = required fields

Are you an elected H & S Rep as noted in the HSE Act?*
First Name* Middle Name  
Last Name* Gender*     Male Female
Ethnicity*  
Residential Contact Details:
Address*
Suburb
City* Post Code*
Phone* Fax  
Email
NZQA/NSI No. Birthdate *  (dd/mm/yyyy)  
Union*
Member ID
Employer Details:
Name*
Contact details of the person who approves leave (eg. HR Manager)
Name*
Please supply either an Employer Postal Address or Email Address (or both)
Address
Suburb ACC Number
City Post Code*
Phone Fax  
Email
Industry*
 
Please select your region (so that we can select a suitable training course for you)
Region*
Please indicate your preferred method of notification* Email Letter
Privacy Statement*

Please note that this registration information (i.e. H&S representative's name, name of the H&S rep's Employer, name of the H&S rep's worksite) may also be used: to randomly survey participants to seek feedback on training programmes; to prepare general management and statistical reports on the WorkSafe Reps training programme for the NZCTU, ACC, Department of Labour, and the individual union identified above - for the purposes of managing the WorkSafe Reps programme.

Individuals will not be identified in any published survey results.

The DOL as well as the individual union may also require this information so that they can identify H&S reps who have been trained in accordance with the provisions of the HSE Act.

Please tick this box to indicate that you have read and understood the Privacy Statement and consent to the information (as specified above) being made available, if required, by NZCTU, ACC, DoL, and individual unions for purposes associated with the H&S programme.