Policy Committees, Work Place Committees and Health and Safety Representatives Regulations (SOR/2015-164)

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Regulations are current to 2025-10-14 and last amended on 2025-03-26. Previous Versions

SCHEDULE(Subsection 9(2))

Employment and Social Development Canada

Emploi et Développement social Canada

(For Labour Program use only)

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WORK PLACE COMMITTEE REPORT

Employer name and mailing address	Committee exemption under paragraph 135(6)(a) of the Act	☐ Yes
Employer name and mailing address	Number of employees represented by committee	[___________]
Business number	Number of employee committee members selected by trade union(s)	[___________]
Committee name/work place/mailing address if different from above	Number of employee committee members selected by employees not represented by trade union(s)	[___________]
	Number of employer committee members selected by the employer	[___________]
	Total number of committee members	[___________]
Name of contact person Telephone number	Name(s) of trade union(s) who selected employee committee members

Year		Jan.	Feb.	Mar.	Apr.	May	June	July	Aug.	Sept.	Oct.	Nov.	Dec.	TOTAL
Meetings	Regular
Meetings	Special
Complaints	Received
	Resolved
	Unresolved
Refusals to work	Received
	Resolved
	Unresolved
Inquiries and investigations
Inspections
Programs, measures and procedures monitored
Health and safety hazards	Identified
	Resolved
	Unresolved
Injuries	Disabling injuries
	Minor injuries
	Time lost due to injuries

Please highlight any special programs, inquiries, unresolved issues or other points that could be significant to the Committee that occurred during the previous 12 months ending December 31. (Attach sheet for additional information.)