If you're a worker who is making a complaint about an employer’s failure to pay wages for duties related to workplace health and safety, as required by the Occupational Health and Safety Regulation, please use this form to submit your complaint to us.

You can complete this form digitally or print it and complete it by hand. If you’d like to complete this form digitally, you must use Adobe Acrobat. If you don’t already have Acrobat on your computer, you can download Adobe Acrobat Reader, a free app, from get.adobe.com/reader.

Please note the form’s functionality will not work properly if the form is opened in an internet browser such as Microsoft Edge or Google Chrome.

To complete and submit the form digitally:

1. Click the Download PDF button. The form will be copied to the Downloads folder on your computer hard drive.
2. Open the form in Acrobat by going to your Downloads folder and right-clicking on the PDF file. Select Open with > Adobe Acrobat Reader.
3. Type your information in the form and sign it. (This short video explains how to create an electronic signature.)
4. Save the form and submit it using the submission instructions on the bottom of the form.