Workplace Investigation Reports On Refusal To Work Page 2
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2WORK PLACE COMMITTEE or SAFETY REPRESENTATIVE INVESTIGATION REPORT
IDENTIFICATION OF INVESTIGATORS
11. Investigation conducted by:
Employee Work Place Committee Member, or
Employee Health and Safety Rep.
Name:
Work phone:
Email address:
and
Employer Work Place Committee Member, or
Employer designated person
Name*:
Work phone:
Email address:
*to allow for an unbiased investigation, should not be the same person listed in Section 2.
DESCRIPTION OF REFUSAL and INVESTIGATION BY COMMITTEE OR HEALTH AND SAFETY REP
12. Date and time the refusal is reported to Work Place Committee or Health and Safety Rep.
Date:
Time:
13. Description of investigation, factors considered, and reasons for decision
14. Decision of Work Place Committee or Health and Safety Rep.
Consensus not reached (describe main points of dissension):
No Danger:
Danger:
Refusal not permitted under Subsection 128 (2):
Agree with employer decision:
Yes
No
Recommendations made to employer:
Yes (describe below)
No
15. Investigation report provided to employer
Employee Work Place Committee Member or
Health and Safety Rep.
Date:
Time:
Employer Work Place Committee Member or
Employer designated person
Date:
Time:
SUPPLEMENTAL INFORMATION / CORRECTIVE ACTIONS REPORT
16. Supplemental information provided by the employer
Date:
Time:
Yes, provided on
No
17. Did the employer take supplemental corrective action in response to the investigation report of the committee or representative?
Date:
Time:
Yes, taken on
No
18. Was the workplace/rep investigation report amended based on above supplemental information / actions?
N/A, (No supplemental information / action provided)
No
Yes, on
Date:
Time:
ESDC LAB1184 (2015-05-002) E
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