The CUPE Ontario Health and Safety Award Nomination Form

Closing date for nominations is April 30, 2024.

Do you know a member who has made a significant contribution on behalf of CUPE members?

CUPE Ontario’s Health and Safety Committee wants to hear from you for their Health and Safety Award.

The award shall be presented at CUPE Ontario’s Annual Convention.

The Committee seeks candidates:

Whose actions have helped others;
Whose activities have:
1. Improved workplace conditions to promote Health and Safety;
2. Helped recognize occupational illnesses or diseases;
3. Solved problems for CUPE members;
4. Advocated on behalf of Health and Safety rights;
5. Achieved victories for Health and Safety;
6. Established precedents.
Who have been a leader and/or activist in Health and Safety.
Who are members in good standing of a CUPE Ontario- affiliated local.

Please note that CUPE staff and members of CUPE Ontario’s Health and Safety Committee who sit on the Award Selection Committee are not eligible for the award.

Nomination Form

Name of Nominee *

Local Union Number *0 / 9

Mailing Address:

Street Address *

Apartment, suite, etc

City *

Province *

Postal Code *

Home Phone *

Work Phone

Occupation *

How many years has the nominee been a CUPE member? *

Submitted By:

Name of Nominee *

Local Union Name *

Local Union Number: *

Mailing Address:

Street Address *

Apartment, suite, etc

City *

Province *

Postal Code *

Home Phone *

Work Phone

Fax Number

Email Address *

Local President Name *

The President of this local has given their endorsement to submit this nomination form.

Yes

Local or Division Executive Member's Name *

A Local or Division Executive Member (who is not the president) has also given their endorsement to submit this nomination form.

Yes

Involvement

Local Union Health and Safety Advocacy

Workplace Joint Health and Safety Committee

WJHSC Current

WJHSC Past (Years)

WJHSC Comments

Local Health and Safety Committee

Local H&S Committee Current

Local H&S Committee Past (Years)

Local H&S Committee Comments

CUPE Ontario Division Health and Safety Committee

CUPE Ontario H&S Committee Current

CUPE Ontario H&S Committee Past (Years)

CUPE Ontario H&S Committee Comments

Other (e.g.: Labour Council, CUPE District Council, etc.)

Other Local Union Current

Other Local Union Past (Years)

Other Local Union Comments

Local Union (General)

Steward/Health & Safety Advocate

Steward/H&S Advocate Current

Steward/H&S Advocate Past (Years)

Steward/H&S Advocate Comments

Local Executive Member

Local Executive Member Current

Local Executive Member Past (Years)

Local Executive Member Comments

Committees (e.g.: Health and Safety, Injured Worker Advocacy)

Committees Current

Committees Past (Years)

Committees Comments

Other (e.g.: Negotiated WSIB language into CBA, etc.)

Other Local Union Gen. Current

Other Local Union Gen. Past (Years)

Other Local Union Gen. Comments

Contribution to Health and Safety at the Local Union Level

Please tell us how the nominee has made a positive contribution in the field of health and safety advocacy at the local union level. Include what the nominee has done, how it was achieved, where, when, and any success stories you wish to share.

What has the nominee done? (Contribution to Health and Safety at the Local Union Level)

How was it achieved? (Contribution to Health and Safety at the Local Union Level)

Where? (Contribution to Health and Safety at the Local Union Level)

When? (Contribution to Health and Safety at the Local Union Level)

Other Contributions to Health and Safety Advocacy

Please tell us if the nominee has contributed to health and safety advocacy at the Ontario Division level. Include what the nominee has done, how it was achieved, where and when.

What has the nominee done? (Other Contributions to Health and Safety Advocacy)

How was it achieved? (Other Contributions to Health and Safety Advocacy)

Where? (Other Contributions to Health and Safety Advocacy)

When? (Other Contributions to Health and Safety Advocacy)

Health & Safety Courses

Please indicate which courses the nominee has taken to enhance their understanding of H&S

Health & Safety and other Related Training

Has the member completed any portion of the Mohawk College H&S related training or Labour Studies program? If yes, please provide a detailed list here:

Other Relevant Courses/Workshops

Has the nominee facilitated any Health & Safety courses? If yes, please provide a detailed list

Closing date for nominations is April 30, 2024.

Closing date for nominations is April 30, 2024.

Do you know a member who has made a significant contribution on behalf of CUPE members?

The Committee seeks candidates:

Please note that CUPE staff and members of CUPE Ontario’s Health and Safety Committee who sit on the Award Selection Committee are not eligible for the award.

Nomination Form

Mailing Address:

Submitted By:

Mailing Address:

The President of this local has given their endorsement to submit this nomination form.

A Local or Division Executive Member (who is not the president) has also given their endorsement to submit this nomination form.

Involvement

Local Union Health and Safety Advocacy

Local Union (General)

Contribution to Health and Safety at the Local Union Level

Other Contributions to Health and Safety Advocacy

Health & Safety Courses

WHSC - Level 1

Committees - Level 2

Law - Level 2

Certification - Core 1

Certification - Core 2

Facilitator Training

Health & Safety and other Related Training

Other Relevant Courses/Workshops

The CUPE Ontario Health and Safety Award Nomination Form

Closing date for nominations is April 30, 2024.

Do you know a member who has made a significant contribution on behalf of CUPE members?

The Committee seeks candidates:

Please note that CUPE staff and members of CUPE Ontario’s Health and Safety Committee who sit on the Award Selection Committee are not eligible for the award.

Nomination Form

Mailing Address:

Submitted By:

Mailing Address:

The President of this local has given their endorsement to submit this nomination form.

A Local or Division Executive Member (who is not the president) has also given their endorsement to submit this nomination form.

Involvement

Local Union Health and Safety Advocacy

Local Union (General)

Contribution to Health and Safety at the Local Union Level

Other Contributions to Health and Safety Advocacy

Health & Safety Courses

WHSC - Level 1

Committees - Level 2

Law - Level 2

Certification - Core 1

Certification - Core 2

Facilitator Training

Health & Safety and other Related Training

Other Relevant Courses/Workshops

Thanks for participating