Work Refusal Investigation Form Work Refusal Investigation Form Step 1 of 11 9% Work Refusal ProcessBefore starting the investigation, the Workplace Refusal Process and applicable definitions must be reviewed with the employee.Click here to open and review the Work Refusal Process with the employee prior to completing the investigationHas the work refusal process and the applicable definitions been reviewed with employee?*Ensure that the employee understands the definitions of "Undue Hazard", "Reasonable Cause to Believe" and "Workplace Violence" Yes No Does the employee wish to continue the work refusal?* Yes No Work Refusal ReportDate of refusal MM slash DD slash YYYY Time of refusal : Hours Minutes AM PM AM/PM Name First Last Employee NumberPositionAboriginal 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 WorkerOtherSchool/Location Name of Supervisor investigating the refusal First Last Date of investigation MM slash DD slash YYYY Time of investigation : Hours Minutes AM PM AM/PM Did the employee immediately report the circumstances of the work refusal to the Administrator or Manager? Yes No Name of Supervisor reported to: First Last Date reported MM slash DD slash YYYY Time reported : Hours Minutes AM PM AM/PM Type of refusal* Work process/task Use of equipment, tool or machinery operation Is the refusal regarding Workplace Violence?* Yes No The work process/task refusal involves:* a student a parent a staff member an unknown person Other Student InformationStudent PEN # Student Initials Student Age Non Student InformationProvide Name (if known) and relationship to employee. If person is unknown, provide details description of the person and any other relevant details. 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)* Injury Risk AssessmentComplete the following to assess the level of risk of injury while performing the work process or taskSeverity 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 Severity of Consequence1*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 HiddenNumber*Injury Risk LevelLow Low - Moderate Moderate Moderate - High High Employee Training and Experience Risk Assessment (Student Related Refusal)Does 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 LevelHiddenTraining and experience risk scoreLow Low - Moderate Moderate Moderate-High High Overall Risk LevelTotal Risk ScoreLow Low - Moderate Moderate Moderate - High High Overall Risk Assessment Summary and RecommendationsBased on the risk assessments: Based on the risk assessments: Based on the risk assessments: Based on the risk assessments: Based on the risk assessments: Based on the risk assessments: Prevention Recommendations Prevention Recommendations Prevention Recommendations Training Requirement Training Requirement Additional Training Recommendations Non Student Violent Risk AssessmentHave 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 ScoreHiddenNon Student Violence Risk ScoreLow Low-Moderate Moderate Moderate-High High Overall Risk Score Non StudentHiddenTotal Risk Score Non StudentLow Low - Moderate Moderate Moderate - High High Use of Equipment, Tools and Machinery Risk AssessmentWhat 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 Use of Equipment, Tool or Machinery Risk LevelHiddenEquipment, tool or machinery training risk scoreLow Low-Moderate Moderate Moderate-High High Overall Risk ScoreHiddenTotal Risk Score EquipmentLow Low-Moderate Moderate Moderate-High High ConclusionTaking into account all relevant and available information and exercising good faith judgment with respect to the hazard with due regard to the worker's training and experience, in your opinion is there an objective, or reasonable, basis for the refusal?* Yes No Please provide the reason(s) why the task would not create an undue hazard to the health and safety of the worker or any other person and share this information with the employee*This information will be sent to sent to the replacement worker you select below if the situation has not been resolved Has the matter has been resolved? (ie: the worker has agreed to return to work)* Yes No Please provide the control measures and/or corrective actions that will taken to ensure the work that has been refused is safe*Will the worker agree to return to work after the above actions are taken?* Yes No Will a replacement worker be needed while the investigation continues or until corrective actions are implemented?* Yes No This 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 Other reason(s)* Name of Replacement Worker* First Last Email of Replacement WorkerAs per WorksafeBC regulation, the replacement worker must be advised of the work refusal in progress, the unsafe condition reported, reasons why the task would not create an undue hazard for them, and their right to refuse unsafe work Further Investigation is requiredAs per WorksafeBC Regulation 3.12, if the matter is not resolved and the worker continues to refuse to carry out the work process or operate the tool, appliance or equipment, the supervisor or employer must investigate the matter in the presence of the worker who made the report and in the presence of a worker member of the joint committee,PLEASE SUBMIT THIS REPORTWhen you submit this report, an email will be send to the replacement worker requesting their assistance and the Worker Refusal Investigation Part 2 From will open. When this form open, you can continue the investigation or save and continue later.