REFUSAL TO WORK FORM

Document # HSE-F-008

Revision No: 0

Release Date: Nov 15th, 2011

Section 1

Reported by Department Date Reported Reference Number

Details of Task

Justification for Refusal

Signatures

Supervisor Manager HSSE Representative

Section 2 (To be completed by the HSSE Department only)

OSH Inspector Notified Date Visited

Yes No Comments

OSH Inspectors Decision

Preventative/Corrective Actions

Comments