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Work Refusal Notification Form

You’re not allowed to assign somebody to perform work that’s currently subject to another worker’s work refusal unless and until you notify the worker to whom you propose to assign the work of the refusal, the reasons for it, why you believe the work is safe and the worker’s own refusal rights. Here’s a template you can adapt for your own use and the circumstances of the particular work refusal.

OHS Refusal Rights

Under [insert Section] of the [insert jurisdiction] OHS Act, a worker may refuse to work or to do particular work at a work site if the worker believes on reasonable grounds that there is an undue hazard at the work site or that the work constitutes an undue hazard to the worker’s health and safety or to the health and safety of another worker or person.

Notification of Current Work Refusal

We want to let you know that another worker (whom we will refer to as the ‘refusing worker’) has exercised their [insert Section] work refusal rights to refuse to perform the work that ABC Company has assigned you to perform. The purpose of this notification is to remind you of your own work refusal rights and provide you the information you to make an informed decision about whether you want to perform the assigned work.

Reasons for Refusing Worker’s Refusal

The refusing worker has refused to perform the assigned work [list the work and reason(s) for refusal] [example: operate the forklift in Area B of the Shipping Department because they contend that the brakes do not work properly].

Reasons ABC Company Believes the Work Is Safe

ABC Company believes that the work refusal is unjustified and that the refused work will pose no danger to the health or safety of any person because [describe the basis for concluding the work is safe] [example: i. ABC Company staff has inspected the brakes of the forklift according to the manufacturer’s instructions and maintenance schedule and identified no problems with the braking system or any of its component parts; ii. A technician has also inspected the brakes and found no problems or defects; iii. There have been no reported problems, complaints or incidents involving the forklift or its braking system; and iv. Other workers who operate the forklift report that they believe it to be safe and have experienced no problems with the brakes.]

Please sign below to acknowledge having received, read and fully understood this notice of work refusal:

Worker name: __________________________________________________

Signature: ______________________________ Date: ___________

(If applicable) JHSC worker member name: ________________________________

Signature: ______________________________ Date: ___________