Teamster Canada Rail Conference Record of Invoked Right to Refuse Dangerous Work Canada Labour Code Part-II / Section-128.1 Refuse Dangerous Work results Form results will be sent to the TCRC National Legislative Board
1) Date of Work Refusal:   Month Jan Feb March April May June July Aug Sept Oct Nov Dec            Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31            Year 2008 2009 2010 2011 2012
2) Member Name:   3) Phone Number:       4) Occupation:   5) Division Number:       6) Name(s) of Other Crew Members:   7) Home Terminal:     8) Railway Name:         9) Location of Refusal (Sub / Mileage / Unit No.):
10) Nature of Refusal
11) Name of Manager Notified:
12) Title of Manager:	13) Time Manager Notified:
14) Was employer notified refusal made under Canada Labour Code Part-II?
Please Select Yes No
15) Did employer attempt to resolve refusal?
Please Select Yes No
(If previous answer yes, what steps were taken to resolve issue?):
(If previous answer no, what actions followed?):
16) Did employer advise you of Part - II Work Refusal Procedure?
Please Select Yes No Not sure
17) Did employer contact Health and Safety Representative?
Please Select Yes No Not sure
18) Name of Health and Safety Representative contacted:
19) Did Health and Safety Representative attend site?
Please Select Yes No
20) Did employer contact Transport Canada Safety Officer?
Please Select Yes No
21) Name of Officer called:	22) Time Notified:
23) Did Transport Canada Safety Officer attend site?
Please Select Yes No
24) Did employer intimidate or threaten you or employees in any way?
Please Select Yes No
(If yes provide nature and details of intimidation or threat.):
25) Describe how refusal was resolved.
26) Your E-mail address:
Should you have additional information please contact the National Legislative Board at (613) - 235-1828