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Application to Extend Audit Scope Out-Of-Province
Company Name:
Date:
Head office Address:
City:
Postal Code:
Province:
WCB Account(s):
COR# :
Province:
WCB Account(s):
COR# :
Province:
WCB Account(s):
COR# :
Auditor Name:
:
Type of Audit
Approx. Start Date of Audit:
Which jursidcition does not have an active field site?
Which jursidcition would you like to use in lieu of for field sites:
Have there been any active field sites, during the current calendar year, in the province with no acitve
sites:
Current Year Audit Sampling Plan
Please breakout all active sites (one per line) * if more lines are required please attach a separate sheet.
Province
Fixed or Field Site
Location
Yes
No
Do you currently have a COR?
Previous Certification (External) Audit Actual Sampling
Please break out all Active Sites (one site per line):
Province
Fixed or Field Site
Location
Included
in Audit?
Total #
Employees
Intended
Interview #
*if "Yes" complete this section, if not continue to page 2
Year of the external audit:
Included
in Audit?
Total #
Employees
#
Interviews
Have there been any significant changes to operations (expansion or contraction of business) since the last
certifying audit?
If so please explain:
*This form is only eligible for the year it is applied for. To achieve a 3 year COR this form must be completed annually, if applicable.
Application to Extend Audit Scope Out-Of-Province
Employer Report of Health and Safety Performance
Employer Trade Name:
Employer Name:
Province:
COR#
Province:
COR#
Province:
COR#
Province:
COR#
Reporting Period Dates: (must be a 12 month period from the date of the application)
Start Date:
to
End Date:
List the details of any fatalities, serious injuries or incidents that occurred only within the previous 12 months in jurisdictions outside of the
provinces that were incluuded in the audit scope.
Description of Incident (what happened, Description of
Was the
Jurisdiction
Date
Location (city,
describe any tools or equipment
injury to worker(s)
worker(s)
(province,
involved, why did the incident occur?)
hospitalized for
town, or
state or other)
2 days or
other)
more?
(Yes)/No)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Note: Serious injuries are defined as an injury or accident that results in a fatality or a worker being admitted to a hospital for more than 2
days. Serious incidents are defined as having the potential to cause serious injury to persons at the worksite. These can include an
unplanned explosion, fire or flood; the collapse or upset of a crane, derrick or hoist; or the collapse or failure of the structural integrity of a
building or structure.
*This form is only eligible for the year it is applied for. To achieve a 3 year COR this form must be completed annually, if applicable.
Application to Extend Audit Scope Out-Of-Province
List the details of any violations of Occupational Health and Safety Legislation that occurred only within the previous 12 months in
jurisdictions outside of the provinces that were included in the audit scope.
Jurisdiction
(province
state or
other)
Date
Location
(city,
town, or
other)
Description of Violation
Have charges been
laid? Was the employer
prosecuted under OHS
Legislation?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Penalty
Imposed by
OHS
Authorities
Signature of President, Director or Senior Officer:
Print Name:
Position / Job Title:
Phone Number:
Email Address:
Please Note: Employers approved to include out-of-province work sites in their audit, may be subject to Employer Review
should fatalities, serious injuries or incidents and/or violations of local occupational health and safety legislation occur on their
out-of-province work site(s) associated with their COR.
In the event of a fatality or serious injury, the employer must contact Enform within 30 days with the details. Enform will
forward this information to the applicable governing body.
*This form is only eligible for the year it is applied for. To achieve a 3 year COR this form must be completed annually, if applicable.