# Form - Work Refusal Record

> Fire Service Safety Management System, version 0.3.3 (2026-10-25). The Human Factor. Document FSSMS-FRM-51.
>
> Canonical: https://thehumanfactor.ca/library/fire-service-safety/form-work-refusal-record
>
> Licence: CC BY-NC-SA 4.0 with the Adopting Agency Grant (https://creativecommons.org/licenses/by-nc-sa/4.0/)
>
> 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.

## 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](https://thehumanfactor.ca/library/fire-service-safety/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](https://thehumanfactor.ca/library/fire-service-safety/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](https://thehumanfactor.ca/library/fire-service-safety/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](https://thehumanfactor.ca/library/fire-service-safety/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.”

> **Note: Customize**
>
> Map the statutory steps in Parts B to D to your jurisdiction’s exact sequence on [J07 Right to Refuse and Reprisal Protection](https://thehumanfactor.ca/library/fire-service-safety/j07-right-to-refuse-and-reprisal-protection); some jurisdictions have the committee co-chairs investigate jointly at step 3, others a single worker member. Add the regulator’s 24-hour number to Part D. Keep a paper copy in every apparatus.

## 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](https://thehumanfactor.ca/library/fire-service-safety/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](https://thehumanfactor.ca/library/fire-service-safety/j07-right-to-refuse-and-reprisal-protection) |

## References