FORM: Notice to employees of an appeal of an occupational health and safety decision

In some cases, an employer who is party to an appeal of an administrative penalty) for an occupational health and safety matter will post a notice to employees of the appeal in one or more conspicuous places. If possible, at least one place of posting must be at or near the equipment or work area to which the penalty relates.
Employer Information
Name of employer (Required)
Contact person name and job title
Mailing Address (Required)
Street address Address line 2 City Province / State Postal / Zip code Country
Phone (daytime) (Required)
Phone (other)
Fax
Phone (daytime) (Required)
Phone (other)
Fax
Notice to Employees

An appeal has been filed of the attached Review Division decision concerning an Occupational Health & Safety (OHS) administrative penalty under the OHS provisions of the Workers Compensation Act.

If you wish to participate in the appeal, contact the Workers’ Compensation Appeal Tribunal at:

150 – 4600 Jacombs Road
Richmond, BC V6V 3B1
WorkSafeBC Review Division decisions (Required)
Review Division decision reference #(s) Date of Review Division decision(s)

NOTE: This Review Division decision is also available on the WorkSafeBC website at www.worksafebc.com.
This notice has been posted at the following locations: (Required)
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the following: (Required)
I confirm the employer posted this Notice to Employees in a conspicuous place at the locations affected by the decision.
Name of signer (Required)
Date signed
YYYY dash MM dash DD
Email address
Enter an email address here if you would like to receive confirmation that WCAT received your form. WCAT will send you a copy of the completed form by mail or email (depending on your preferences as shown on the notice of appeal or participation form).
Enter Email Confirm Email
Phone
This field is for validation purposes and should be left unchanged.

If you’d prefer to mail or fax a printed copy, use this version: Notice to employees of an appeal of an occupational health and safety decision (PDF, 32KB).

Review Division decision reference #(s)	Date of Review Division decision(s)

Employer Information

Notice to Employees