Occupational Health and Safety Tribunal Canada
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Occupational Health and Safety Tribunal Canada

www.ohstc.gc.ca

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Application To Appeal

The HTML version of this application form is presented as an example only. To fill out and print an Application to Appeal please use the accessible PDF Version (32 KB).

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Occupational Health and Safety Tribunal Canada
Arms of Canada




Tribunal de santé et sécurité au travail Canada
Ottawa, Canada K1A 0J2

Canada Labour Code Part IIOccupational Health and Safety

Application to appeal

I wish to appeal a decision regarding a refusal to work: that a danger does not exist


 

That the danger is a normal condition of employment


 

That the refusal puts the life, health or safety of another person directly in danger


 


I wish to appeal a direction


 


I wish to appeal for a stay of the direction


 


Name of the Appellant:
______________________________________________


Title:
______________________________________________


Address:
______________________________________________


Telephone Number:
______________________________________________


E-mail Address:
______________________________________________


Respondent:
______________________________________________


Name of the Official delegated by the Minister of Labour who rendered the Decision(s) or Direction(s):

______________________________________________


Date of Decision(s) or Direction(s):

______________________________________________


Reasons for Appeal:
______________________________________________


Date____________________ Signature_____________________________

Please include a copy of the decision(s) or direction(s) if available.

47 Clarence Street, Office 200, Ottawa, Ontario, K1A 0J2
Telephone number: 613-437-0612 or 1-866-440-3343
Facsimile number: 613-437-0600

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Date Modified:
2015-05-19