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 PDF Version.

Occupational Health and Safety Tribunal Canada

Tribunal de santé et sécurité au travail Canada

Arms of Canada

Ottawa, Canada K1A 0J2

Canada Labour Code Part II – Occupational 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 apply for a stay of the direction


Name of the Appellant:



Telephone Number:

E-mail Address:


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:



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

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

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