Work refusal investigation Form Part 2 Work Refusal Investigation Form Part 2 Step 1 of 14 7% Please indicate whether your wish to continue on to the next section immediately , or save and continue once you have arranged for the employee and JHSC worker rep to meet with you to investigate further*NOTE: this investigation meeting must take place without undue delay If you save this report and continue later, you must select “Continue investigation now” to move to the next section. Continue investigation now Save the investigation to allow time to arrange for the employee and JHSC worker rep to meet with you This field is hidden when viewing the formPreliminary InvestigationDate of continued investigation* MM slash DD slash YYYY Time of continued investigation* : Hours Minutes AM PM AM/PM Name of the JHSC Worker Representative* First Last This field is hidden when viewing the formWork Refusal ReportThis field is hidden when viewing the formDate of refusal MM slash DD slash YYYY This field is hidden when viewing the formTime of refusal : Hours Minutes AM PM AM/PM This field is hidden when viewing the formName* First Last This field is hidden when viewing the formEmployee Number*This field is hidden when viewing the formLocationSelect…First ChoiceSecond ChoiceThird ChoiceThis field is hidden when viewing the formPositionAboriginal Support WorkerAccounts Payable TechnicianAdmin AssistantAdministrative OfficerAdministratorAssistant Secretary-TreasurerBus DriverBus MonitorBuyerCabinetmakerCafeteria AssistantCareer AdvisorComm And Events SpecialistCommunity School CoordinatorCounsellorCrosswalk SupervisorCustodianDelivery and courier service driversDirector – FacilitiesDirector-Info Sys & TechnologyDistrict PrincipalEduc. Software System Coord.Equipment OperatorFamily Support WorkerForeman Trades CertifiedGroundskeeperHomestay Coordinator-IspIt Support TechnicianLabourerLibrary TechnicianManager-Facilities ServicesManager-Maint/MechanicalNoon SupervisorOccupational TherapistOtherPayrollPending – Cupe 1260 AssignmentPrincipalProfessional Serv SupervisorProgram Asst-Second LanguageRoute DriverSchool Board TrusteeScience TechnicianSEASettlement WorkerSocial and community service workersSpeech Language PathologistStrong Start FacilitatorStudent Helper/ShopperSupervisorTeacherTech Support SpecialistTechnicianTrades Cert CarpenterTrades Cert Carpenter LocksmitTrades Cert Carpenter RooferTrades Cert ElectricianTrades Cert GlazierTrades Cert Hvac MechanicTrades Cert MechanicTrades Cert PainterTrades Cert Plumber GasfitterUtility PersonYouth Care WorkerOtherName of Supervisor investigating the refusal*Email* This field is hidden when viewing the formDate of investigation MM slash DD slash YYYY This field is hidden when viewing the formTime of investigation : Hours Minutes AM PM AM/PM This field is hidden when viewing the formDid the employee immediately report the circumstances of the work refusal to the Administrator or Manager? Yes No This field is hidden when viewing the formName of Supervisor reported to: First Last This field is hidden when viewing the formDate reported MM slash DD slash YYYY This field is hidden when viewing the formTime reported : Hours Minutes AM PM AM/PM This field is hidden when viewing the formType of refusal* Work process/task Use of equipment, tool or machinery operation This field is hidden when viewing the formIs the refusal regarding Workplace Violence?* Yes No This field is hidden when viewing the formThe work process/task refusal involves:* a student a parent a staff member an unknown person This field is hidden when viewing the formStudent InformationThis field is hidden when viewing the formStudent PEN #*This field is hidden when viewing the formStudent Initials*This field is hidden when viewing the formStudent Age*This field is hidden when viewing the formNon Student InformationProvide Name (if known) and relationship to employee. If person is unknown, provide details description of the person and any other relevant details. Review the Basis of the Work RefusalDescribe the work process/circumstance/condition that may expose the employee or other person to an excessive or unwarranted risk of injury or occupational disease*Provide the specific hazard(s)/reason(s) for invoking a refusal of unsafe work (include the circumstances, conditions and/or series of events leading up to the refusal)* Review the Injury Risk AssessmentReview the Injury Risk Assessment and Training/Experience Assessment completed in part 1 (and sent to you via email) with the worker and the JHSC Rep. If they don’t agree with this Risk Assessment, continue to next page and make the necessary changes.After reviewing the Basis of the Work Refusal and the Risk Assessments with the employee and Worker/Union Representative(s), do all parties agree that the outcome of the risk assessments are accurate?* Yes No Revised injury Risk AssessmentSeverity of Consequence*Should the work be carried out and an incident/accident occurs, what would be the likely outcome Several fatalities Fatality Serious injury or illness; permanent disability Temporarily disabling injury/illness Injury or illness requiring medical attention Minor cuts, bruises, irritations Level of Exposure* Continuously (80-100% of the time) Frequently (60-79% of the time) Usually (40-59% of the time) Occasionally (15-39% of the time) Rarely (5-10% of the time) Very rarely (1-4% of the time) Extremely rare (<1% of the time) Possibility of Consequence*Should the work be carried out, what is the likelihood of an incident/accident occurring resulting in the severity of consequence Most likely and expected Quite possible, would not be unusual Possible; has happened within the past year Remotely possible; has been know to happen Very remote possibility; hasn’t happened in recent years Extremely remote; has not happened despite exposure This field is hidden when viewing the formNumber*Injury Risk LevelLowLow – ModerateModerateModerate – HighHigh Revised Employee Training and Experience Risk AssessmentDoes the student have a Positive Behaviour Support Plan (PBSP)?* Yes No Has the employee reviewed the PBSP and understood the strategies?* Yes No Is there an Employee Safety Plan (ESP) in Place?* Yes No Has the employee reviewed the ESP and understood the protocols and procedures?* Yes No Does the employee have an educational background in special education services?*(ie: SEA, ABA, YCW, Resource Teacher, Integrated Support, Learning Support) Yes No How much experience does the employee have working in special education services?* < 6 months 6 months-1 year 1 – 3 years 3-5 years 5-10 years >10 years Has the employee had any NVCI or Ukeru training in the past 2 years?* Yes No Training And Experience Risk LevelThis field is hidden when viewing the formTraining and experience risk scoreLowLow – ModerateModerateModerate-HighHigh Overall Risk LevelTotal Risk ScoreLowLow – ModerateModerateModerate – HighHighRisk Assessment Summary and RecommendationsBased on the risk assessments above:Based on the risk assessments above:Based on the risk assessments above:Prevention RecommendationsPrevention RecommendationsTraining RequirementTraining RequirementAdditional Training Recommendations Review of the Non Student Violent Risk AssessmentReview the following RA with the worker and the JHSC Rep. If they agree with this Risk Assessment, continue to next page. If not, make the necessary changes and then continue to next page.Have the police been notified? Yes No, but the situation warrants it This situation doen not warrant police involvement What is the current status of the police investigation? Case has just been opened Case is still under investigation Case is closed/resolved Has the employee received any training on how to prevent and/or respond to this type of violence?(ie: How to Deal with Irate People, Bullying and Harassment Training, Working Alone, Safe Handling of Money, Getting to and from Work Safely, etc.) Yes No Have any other actions been taken to mitigate the situation? Yes No Describe the actions that have been taken to mitigate the situationWere the actions taken successful? Yes No Non Student Violence Risk ScoreLowLow-ModerateModerateModerate-HighHigh Review ofUse of Equipment, Tools and Machinery Risk AssessmentReview the following RA with the worker and the JHSC Rep. If they agree with this Risk Assessment, continue to next page. If not, make the necessary changes and then continue to next page.What type of equipment, tool or machinery is referenced in the work refusal*Is the equipment, tool or machinery in good operating condition?(guards are in place, preventative maintenance is performed regularly, safety devices are in place, etc.) Yes No Has the employee been provided training and instruction on the safe operation of the equipment, tool or machinery? Yes No Has the employee been trained on the safe job procedures? Yes No Is the employee required to have certification in order to operated the equipment, tool or machinery?* Yes No Is the employee currently certified? Yes No Does the employee have experience operating the equipment, tool or machinery? Yes No How many years experience does the employee have? <6 months 6 months-1 year 1-3 years 3-5 years >5 years Review Use of Equipment, Tool or Machinery Risk LevelEquipment, tool or machinery training risk scoreLowLow-ModerateModerateModerate-HighHighOverall Risk ScoreTotal Risk Score EquipmentLowLow-ModerateModerateModerate-HighHigh Review the control measures in place and/or to be takenControl measures and/or corrective actions that will taken to ensure the work that has been refused is safe for this worker Taking in to account the injury and experience risk assessments and the implementation of the recommended controls to reduce the risk, in your opinion is there an objective, or reasonable, basis for the refusal?* Yes No Please provide any additional control measures and/or corrective actions that have or will be taken to ensure the work that has been refused is safe for this worker and other workers*If there were additional recommendations provided by the risk assessment, please list what additional actions will be taken.Will the worker agree to return to work after the above actions are taken?* Yes No Will a replacement worker be needed while the corrective actions are being implemented and/or while the investigation continues??* Yes No Replacement Worker NotificationCurrent Replacement Worker* First Last Email of Current Replacement WorkerWhen this form is submitted, an email will be sent to this worker requesting that they continue to perform this task until further notice. This field is hidden when viewing the formThis task would not create an undue hazard for this worker because they:*Select all that apply Have the required training Have the required experience Have reviewed and understood the Employee Safety Plan Have reviewed and understood the Positive Behaviour Support Plan Have had NVCI training Have worked with this student before Other Will the replacement worker be the some as above?* Yes No New replacement worker name First Last This task would not create an undue hazard for this new worker because they:*Select all that apply Have the required training Have the required experience Have reviewed and understood the Employee Safety Plan Have reviewed and understood the Positive Behaviour Support Plan Have had NVCI training Have worked with this student before Other Email of New Replacement WorkerWhen this form is submitted, an email will be sent to this worker requesting that they perform this task until further notice. Other reason(s)* Work Refusal Investigation Part 3If, after this investigation, the work refusal has not been resolved and the worker continues to refuse the work, the Administrator/Manager AND the worker must contact WorksafeBC to have a WorksafeBC Officer investigate the matter to determine if there is an undue hazard. WorksafeBC Prevention Line: Phone: 604.276.3100 (Lower Mainland) Toll-free: 1.888.621.7233 (1.888.621.SAFE) The worker is to be assigned to alternate work until the matter is resolved.Note:Workers are protected from prohibited action under section 3.13 when exercising their right to refuse unsafe work, however, where a prevention officer has made a finding that the investigation into a work refusal under section 3.12 has not identified an undue hazard, and the worker refuses to return to work, the worker is no longer protected by the provisions of section 3.13 of the Regulation.Press submit to save your investigation
