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

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.

I confirm that I have read the Anonymity and Disclosability Policy at the end of this form

Your Details

Name	Name of trade union you represent

*Contact details for preferred method of response from HSE (please provide at least one method of contact)
Email	Phone/Mobile No
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

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

Anonymity and Disclosability Policy – see guidance at end of form.

Anonymity

HSE recognises that it is difficult for people to raise concerns and that they may be vulnerable ie from fear of dismissal or fear of other repercussions. Therefore, HSE will not disclose your name if you do not want them to. However, we do need your name and correct contact details in case we need to clarify any points with you, so it is important that you provide this information, otherwise HSE will not be able to investigate your concern.

This is because we are not able to substantiate or discuss the information with you or ensure that it is not a malicious complaint.

Disclosability

HSE's policy is to pursue all defined concerns, unless the Notifier will not allow HSE to disclose that a concern has been raised and a vulnerable person is not involved.