Forms and Checklists

The Family Services and Housing Workplace Safety and Health Program Manual contains all of the policies, procedures, checklists and forms associated with the Workplace Safety and Health Program.

The following forms and checklists are included here for quick reference and for ease of printing. Please refer to the appropriate section in the manual for detailed information on safe work procedures and how to use the following forms and checklists.

• First Aid Supplies Request Form (PDF 27 KB)
• Notice of Injury Form (PDF 74 KB)
• Reporting a workplace safety concern (PDF 566 KB – Element 2 from the Manual)
  • Resource 6: Worker Hazard Concern Report Form (PDF 28 KB)
• Reporting a Right to Refuse (PDF 179 KB – Element 9 from the Manual)
  • Resource 26: Refusal to Work Report Form (PDF 25 KB)
• Working alone (PDF 566 KB – Element 2 from the Manual)
  • Resource 14: Emergency Contact Information Form (PDF 23 KB)
  • Resource 15: Working Alone Sign-In/Sign-Out Sheet (PDF 32 KB)
  • Resource 16: Reporting of Unknown Whereabouts of Worker Form (PDF 19 KB)
  • Resource 17: Check-In Procedure Checklist (PDF 12 KB)
  • Resource 18: Travel Information Form (PDF 30 KB)
  • Resource 19: Vehicle Inspection Lists (PDF 32 KB)
• Orientation/Training – see Element 4 and Element 8 from the Manual for more information
  • Resource 21: Supervisor’s New Employee WSH Orientation Checklist (PDF 24 KB)
  • Resource 24: Family Services and Housing Workplace Safety and Health Training Plan (PDF 43 KB)
• Documenting and investigating a workplace incident (PDF 179 KB – Element 9 from the Manual
  • Resource 27: Supervisor’s Incident Report Form (PDF 40 KB)
  • Resource 28: Incident Investigation Summary Report Form (PDF 38 KB)
• Workplace Inspections (PDF 90 KB – Element 5 from the Manual)
  • Resource 22: Workplace Inspection Form (PDF 56 KB)
• Identifying hazards in the workplace (PDF 566 KB – Element 2 from the Manual)
  • Resource 2: Hazard Identification Checklist (PDF 35 KB)
  • Resource 5: Job Hazard Analysis Worksheet (PDF 28 KB)
  • Resource 8: Office Ergonomics Risk Factor Checklist (PDF 283 KB)
  • Resource 9: Ergonomic Consultation Request Form (PDF 66 KB)
• Review of Program (for WSH Committees) (PDF 70 KB – Element 11 from the Manual)
  • Resource 33: Annual Worksite WSH Program Review Form (PDF 28 KB)
  • Resource 34: Department of Labour Evaluation Checklist (PDF 31 KB)