Workplace Health & Safety Decisions/Orders/Administrative Penalty

Complete and submit this form to receive information relating to an employer assessment decision. For more information about requests for disclosure please contact the Information Management Unit at 867-667-5645.

This information is being collected for the purposes of administering and enforcing the Workers’ Safety and Compensation Act and is collected under the authority of that Act and the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the Privacy Officer at WSCB at the above listed address or at (867)667-5645 or 1-800-661-0443.

Applicant Information

As shown on government ID

Workplace Health & Safety Decisions/Orders/Administrative Penalty

Parties named in decision/order:

Receiving Disclosure

Signature, Consent & Declaration