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Refusal To Work Form: Section 1

This document is a refusal to work form that allows employees to report tasks they feel are unsafe and refuse to complete the work. The form collects information about the reported task, the employee's justification for refusal, and signatures from supervisors and managers. It also has a section for the health and safety department to document if an inspector was notified, the inspector's decision, any preventative or corrective actions required, and notes from a health and safety representative.

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Tamara Johnson-Pariag
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315 views1 page

Refusal To Work Form: Section 1

This document is a refusal to work form that allows employees to report tasks they feel are unsafe and refuse to complete the work. The form collects information about the reported task, the employee's justification for refusal, and signatures from supervisors and managers. It also has a section for the health and safety department to document if an inspector was notified, the inspector's decision, any preventative or corrective actions required, and notes from a health and safety representative.

Uploaded by

Tamara Johnson-Pariag
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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REFUSAL TO WORK

FORM
Section 1
Reported by

Department

Document #

HSE-F-008

Revision No:

Release Date:

Nov 15th, 2011

Date Reported

Reference Number

Details of Task

Justification for Refusal

Signatures
Supervisor

Manager

Section 2 (To be completed by the HSSE Department only)


OSH Inspector Notified
Yes
No
Comments
OSH Inspectors Decision

Preventative/Corrective Actions

Comments

HSSE Representative

Date Visited

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