Skip to content
 

Form

Form - Work Refusal Record

Document FSSMS-FRM-51Stage 1Revision 2Version 0.3.3

Topic pages open on your jurisdiction, and requirements tables show its line. You can change this on any page.

Purpose and use

The record of every exercise of the statutory right to refuse unsafe work and of every stop-work call that was not resolved by an immediate “yes.” The supervisor completes Parts A and B at the time; the JOHSC worker member and the senior officer responsible for health and safety complete Parts C and D if the refusal goes that far; the health and safety officer completes Part E. The statutory steps are those of the applicable OHS statute, as recorded in Policy - Right to Refuse Unsafe Work and Stop-Work Authority section 5.1; each jurisdiction’s sequence, and any limit it places on the right for firefighters, is on J07 Right to Refuse and Reprisal Protection. The record is never placed in a personnel file, and a refusal or stop-work call made in good faith is never the subject of reprisal.

For the member. You were right to speak up. This record exists to show what you saw, what was done about it, and what the department learned. It will not be used against you. You may have a JOHSC worker member, a union or association representative, or a colleague with you at every step.

Part A: The refusal or stop-work call

# Field Entry
A1 Type: ☐ Statutory refusal ☐ Stop-work call under the department’s authority ☐ Stop-work call that became a refusal
A2 Member (role, station, status: career / volunteer / paid-on-call / student)
A3 Date and time
A4 Location and activity (station task, training evolution, incident number and assignment, driving)
A5 The work, tool, equipment, apparatus or facility refused
A6 The member’s grounds, in the member’s words (what they saw; what they believed could happen; to whom)
A7 How the call was made (to whom, by role; face to face / radio / phone); the words used if a stop-work call
A8 Supervisor receiving the refusal (role)
A9 Member’s initials and date (optional)

Part B: Step 1 and 2, supervisor’s investigation (immediately, with the member present)

# Field Entry
B1 Supervisor’s acknowledgement (what was said in reply; time)
B2 JOHSC worker member or health and safety representative present (role; time arrived); or colleague chosen by the member (role) if neither available at once
B3 Accompaniment requested by the member (union / association / colleague; role)
B4 What the supervisor found (conditions, equipment, staffing, procedure, information)
B5 Hazard confirmed? (yes / no / partly) and the reasoning
B6 Remedy applied (what; by whom, by role; time)
B7 Member’s position after step 2: ☐ satisfied, work resumed ☐ continues to refuse on reasonable grounds
B8 Interim assignment of the member (other reasonable work; safe location); pay or credit continues (yes)
B9 Was another member assigned the refused work? (yes / no; told of the refusal and the reasons: yes; by whom, by role; time)
B10 At an incident: incident commander informed (time); action within the action plan (withdraw / hold / change tactics / ISO assessment / risk assessment explained and accepted)
B11 Supervisor’s initials and date

Part C: Step 3, JOHSC worker member’s investigation (if unresolved)

# Field Entry
C1 JOHSC worker member (role); co-chairs involved (roles) as the jurisdiction provides
C2 Date and time of investigation
C3 Findings
C4 Advice to the member and the employer
C5 Member’s position after step 3: ☐ satisfied ☐ continues to refuse
C6 Initials and date

Part D: Step 4, regulator (if unresolved)

# Field Entry
D1 Regulator notified by (role); date and time; officer spoken to; reference
D2 Officer’s attendance or decision (date; summary; order reference if any)
D3 Work resumed or remedied (date; on what basis)
D4 Senior officer responsible for health and safety initials and date

Part E: Learning and follow-through (health and safety officer)

# Field Entry
E1 Record reference
E2 Reported into the learning program (date); triage date; tier (Tier 1 if resolved at scene; Tier 2 if not) (Form - Event Triage Record)
E3 Register items opened (references)
E4 Feedback to the member within 30 days (date; summary of what was found and what changed)
E5 JOHSC received the record (meeting date)
E6 Reprisal check: any adverse treatment reported? (no / yes: date raised, to whom by role, response date, outcome)
E7 Recognition considered? (yes / no)
E8 HSO initials and date

Fields

Field Type Required Who completes
Type Single choice Yes Supervisor
Member role, station, status Lookup Yes Supervisor
Date and time Date-time Yes Supervisor
Location and activity Free text; incident lookup Yes Supervisor
Work refused Free text Yes Supervisor
Member’s grounds Free text, member’s words Yes Supervisor with member
How the call was made Choice; free text Yes Supervisor
Supervisor receiving Role Yes Supervisor
Member initials Text; date No Member
Acknowledgement Free text; time Yes Supervisor
JOHSC worker member or colleague present Role; time Yes Supervisor
Accompaniment Choice; role No Supervisor
Findings Free text Yes Supervisor
Hazard confirmed Choice; free text Yes Supervisor
Remedy Free text; role; time Yes if hazard found Supervisor
Member’s position after step 2 Choice Yes Supervisor with member
Interim assignment; pay continues Free text; yes Yes if refusal continues Supervisor
Another member assigned; told Yes/no; yes; role; time Yes Supervisor
Incident commander action Time; choice Yes if at incident Supervisor
Supervisor initials Text; date Yes Supervisor
Step 3 fields Roles; date-time; free text; choice Yes if step 3 JOHSC worker member
Step 4 fields Role; date-time; free text; reference Yes if step 4 Senior officer responsible for H&S
Record reference System identifier Yes Records system
Learning program entry; triage; tier Dates; choice Yes HSO
Register items References No HSO
Feedback to member Date; free text Yes HSO
JOHSC received Date Yes HSO
Reprisal check Choice; dates; role; outcome Yes HSO with JOHSC worker co-chair
Recognition considered Yes/no Yes HSO
HSO initials Text; date Yes HSO

Records

Kept with the event file in {{Records system}} per 05 Document Control and Records, never in a personnel file. Every record goes to the JOHSC at its next meeting. The regulator receives the record on request as the statute provides. Counted for the indicator “stop-work calls and refusals made, and the share reviewed for learning without reprisal.”

Jurisdiction requirements

This chapter relies on the following legal requirements, which differ by province and territory. Check your jurisdiction’s section on each topic page before adopting it.

Topic What to check in your jurisdiction Page
Joint Committee and Health and Safety Representative Who investigates at step 3 (a committee worker member, the co-chairs jointly, or a health and safety representative) and the committee’s role in refusals (Part C) J05 Joint Committee and Health and Safety Representative
Right to Refuse and Reprisal Protection The right to refuse and its statutory steps; whether another worker assigned the work must be told of the refusal; whether pay continues; any carve-out that limits the right for firefighters at incidents; and protection from reprisal (Parts A to E) J07 Right to Refuse and Reprisal Protection

References

© 2026 The Human Factor · Licensed under CC BY-NC-SA 4.0 with the Adopting Agency Grant

General information only, not legal, medical or other professional advice. Verify every requirement against the current official text of the law, standards and manufacturer instructions that apply to you. Obtain your own legal review and consult your joint health and safety committee before adopting anything. You adopt, adapt, implement and rely on this material entirely at your own risk and on your own responsibility. Full terms: Terms of Use, thehumanfactor.ca.

Copyright, licence and legal notices

Connections

Pages linked to and from this page.