Nomination Form for Employee Representatives for PIPSC


Committee on Occupational Safety and Health (COSH)

The following PIPSC Regular Members nominate

Candidate’s Name (Printed):

As employee representative / employee co-chair for PIPSC to the Committee on Occupational Safety and Health (COSH) at :

Name of Research Center, Program or Branch (Printed) :

Name (Printed) / PIPSC Membership No. / Building & Phone No. / Signature and Date




I, __ , hereby accept the nomination.

Candidate’s Name (printed)

Candidate’s Signature

The completed nomination form must be sent to the administrative assistant responsible for the NRC RO/RCO Group by emailing it to the PIPSC at

Candidate and nominators must be members of PIPSC. All nominations will need to be approved by the NRC RO/RCO, IS or LS Group Executive depending on the classification of the candidate.