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OHS reporting form

This form is sent to the AUPE occupational health and safety (OH&S) department for review. After review, they will respond to you and will forward this information to your assigned Membership Services Officer (MSO) so they are aware of the work site concern. AUPE does not send this information to your employer on your behalf.

Reporting OHS concerns to the employer is a right and duty of all workers, under Section 5 of the OHS Act. Your employer cannot take disciplinary action against you for exercising your OHS rights. Section 18 of the OHS Act protects all workers, who exercise their rights under OHS. Please ensure you have reported your concern to the employer.

Personal information

Your six-digit number is on your membership card
Include an area code. Example: (780) 123-4567

Work information

Worksite address

Issue information

Were you injured or made ill as a result of your health and safety concern?
Have you filed a Workers' Compensation Board report?

Issue reporting

Have you reported this concern to your supervisor/employer?
The information you provide in the following form does not replace your responsibility to report any and all occupantional health and safety (OH&S) concerns directly to your employer. All workers are required under legislation to report concerns directly to their employer, as per Section 5(e) of the OH&S Act.
Who did you report your concern to?
How did you report your concern?
Did your supervisor resolve your concerns?
Have you advised your joint work site health and safety committee of your concern?
If you do not know who your Health and Safety representative is, please ask your Chapter Chair who to contact.
Who did you advise of your concern?
Have you notified your Membership Services Officer of your concern?
Who did you notify?

By providing your name, you are allowing AUPE to collect and share information for purposes of statistical tracking, resolving and monitoring occupational health and safety (OH&S) issues on the worksite.

This information will not be shared with your employer without your permission.

Your personal information is collected under the authority of Personal Information Protection Act (PIPA). If you have any questions about the collection of your personal information please call the Member Resource Centre at 1-800-232-7284 or 780-930-3300 and ask to speak to the Privacy Officer.