Health and Safety

Executive

Trade Union Safety Representative - raising a concern about workplace health and safety

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This form is for Trade Union representatives only to report health and safety concerns. It is not for others making a complaint about or reporting a workplace issue. Advice on this is available on the HSE website.

This form should only be used by trade union appointed safety representatives who wish to report health and safety concerns that

have caused, or have the potential to cause, significant harm, that have not been resolved despite using their powers under the

Safety Representatives and Safety Committees Regulations 1977.

Anonymity and Disclosability Policy

*Please confirm that you have read the policy

Your details

*Title

*Forename

*Family Name

*Name of trade union

*Contact details for preferred method of response from HSE (please provide at least one method of contact)

E-Mail

Phone / Mobile No (Daytime)

Address

*Can HSE disclose your name when we follow up your concern?

Yes

No

If No, HSE may be unable to investigate the issue. If telling the workplace that you have raised a concern will cause

you difficulty, please explain why (see Anonymity and Disclosability Policy)

Escalation

*Have you escalated this matter to the appropriate senior

representative or trade union official?

Yes

No

Name of person

Position

Contact details

Date escalated

If No, please explain why

Do you know if this is only a local matter?

Yes

No

Do you know if this is an industry wide matter?

Yes

No

Health and Safety

Executive

Trade Union Safety Representative - raising a concern about workplace health and safety

Zoom

Concern details

*Who is causing your concern?

Registered name

Trading name

Organisation name

Principal contractor

Sub-contractor

*Head office address (if known)

*Location of concern - please provide details for where the activity/concern is taking place (including names of sites and

post codes where applicable)

*Incident details - please provide full details of what has happened, or what could happen, to cause your concern and

why including dates where possible

*Have you taken any action under the Safety Representatives and

Safety Committees Regulations 1977?

Yes

No

Action taken - please give full details with dates

Response - what was the employer's or organisation's response? (Please give full details with dates)

If no, please explain why

Sharing of information

*Do you agree to HSE sharing all the information you give on this form with all

trade unions to help monitor the use of the Safety Representatives and Safety

Committees Regulations 1977?

Yes, I agree

No, I do not agree