Get Work Refusal Form

Filling out the Work Refusal Form is an essential step for employees who encounter unsafe work conditions. This guide provides clear instructions to help users navigate the online process effectively.

Follow the steps to complete the Work Refusal Form with ease.

1. Click ‘Get Form’ button to access the Work Refusal Form and open it in a digital editor.
2. Begin by entering your name in the ‘Employee Name’ field. Ensure that the name matches the one on your identification.
3. Next, fill in the ‘Date’ field to indicate when you are submitting the form. This is important for record-keeping.
4. In the ‘Supervisor’ field, provide the name of your immediate supervisor to whom the concern is being reported.
5. Record the ‘Time reported’ to document when the concern was raised.
6. Identify the ‘Health and Safety Representative’ responsible for communicating the refusal. Provide their name in the designated space.
7. In ‘SECTION 1,’ describe the job assigned to you that you feel is unsafe. Be as detailed as possible to convey the specific situation.
8. In ‘SECTION 2,’ await the supervisor's response regarding your concern. Indicate their response by checking the appropriate box and providing any recommendations offered.
9. If the supervisor feels the job is unsafe, ensure that they sign and date the form indicating any steps taken or recommendations provided.
10. In the event that the job is considered safe, you will need to indicate whether you agree with this assessment or not by signing the relevant statement.
11. In ‘SECTION 3,’ notify if a Federal Health and Safety Officer and Safety Coordinator have been informed. Fill in the respective dates and times.
12. Describe any duties assigned to you while awaiting the inspector’s arrival in the provided section.
13. In ‘SECTION 4,’ complete the name of the person requested to perform the assignment that you refused.
14. The health and safety representative should confirm that they have communicated the situation to the worker. Secure their signature.
15. Finally, ensure that you sign and date the form before submitting. Save your changes, and consider downloading or printing the completed form for your records.

Complete your documents online today for a more efficient process.