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Workplace Investigation Reports On Refusal To Work

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Employment and

Emploi et

PROTECTED WHEN COMPLETED - B

Social Development Canada

Développement social Canada

WORKPLACE INVESTIGATION REPORTS ON REFUSAL TO WORK

REFUSAL TO WORK INVESTIGATION EMPLOYER REPORT

IDENTIFICATION OF PARTIES

1. Employer

Legal name (or department):

Workplace address:

Work phone:

2. Employer's Investigator

Name:

Title:

Work address:

Work phone:

Email address:

3. Refusing Employee

Name:

Title:

Work address:

Work phone:

Email address:

Check the Box if the refusing employee is also the designate person representing for multiple refusing employees, and attach a list with the above contact information

for each of the refusing employees

DESCRIPTION OF REFUSAL AND INVESTIGATION BY EMPLOYER

4. Location of refusal:

5. Employee's reasons for believing danger exists. (report lab1069):

6. Events leading up to the refusal:

7. Date and time the refusal is reported to the employer:

Date:

Time:

8. Description of investigation, factors considered, and the reasons for decision:

9. Decision of employer:

No Danger, (describe any corrective action taken):

Danger, (describe any corrective action taken):