A&D Violation Referral Form – Construction Labour Relations

A & D Violation Referral Form

For Local 146 Boilermakers referrals, please use BCABEAP A&D Policy Violation Referral Form.

For Locals 254 and 424 Electrician referrals please use ECAA’s A&D Policy Violation Referral Form.

For assistance please contact CLRA 780-451-5444, or Homewood Health – TPCM 780-493-0725. You may also fill out the CLRA Contact Request Form.

Upon submission, if you do not receive an email notification, and the notification is not in your junk or spam email folder, please contact CLRA directly.

Did the violation occur at (or for employment at) a work site in Alberta? YesNo
Where did the violation occur? At WorkOff Work

CEFAP only covers individuals working in the province of Alberta.

Date of Violation giving rise to referral*:

First Name of Worker*:

Last Name of Worker*:

A&D Program ID:

Local*:

Test Mode(Please Ignore)*:

Trade*:

Notification of this violation is forwarded on your behalf to the union local you have designated. An error in the Union Local # designation results in a breach of privacy of your workers information. To ensure accuracy, please confirm you have correctly identified the union local number.

YesNo

Mandatory Case Management Trade:

Referring Organization Contact Information

Legal Name of Organization Submitting Referral (please avoid abbreviations)*:

Name of individual making referral*:

Position*:

Email 1*:

Email 2:

Phone Number*:

Project/Dispatch Information

Name of Project & Site*: Name of contractor employing/intending to employ worker referred (if different from referring organization):

Date of Dispatch*:

Work Start Date*:

The individual worker was under the following Alberta Collective Agreement:ConstructionMaintenanceFab ShopMod YardPipelineCrane RentalOverburdenHeavy ConstructionOther (explain)

Was the testing performed in accordance with the Canadian Model Alcohol and Drug Work Rule? (i.e. breath alcohol with confirmation plus drug panel urine-based laboratory analysis with MRO review of non-negative results) YesNoN/A

This referral is in respect to the following violation:Camp InfractionTransportation Infraction

Please note particulars:

Reason for violation:Positive alcohol & drug testRefusal to testEvidence of substitution or tamperingFailure to provide adequate sample

Shift Cycle:

Days in Cycle:

Please attach a copy of the COMPLETED Contractor Template Letter provided to the worker. If you have not completed the template letter HERE to access the Mandatory Case Managed Aftercare Workers template and HERE for the Non-Case Managed Aftercare Workers template. (required)

Please attach copy of the Dispatch Slip & A&D Test Results if applicable & available You may upload a maximum of two PDF documents, for multi-documents submissions please combine your documents into a single file before uploading.

Personal contact information of worker being referred

First Name*:

Last Name*:

Home or Cell Telephone*:

Alternative Home or Cell Telephone:

Email*:

Address:

Contractor/Union: additional comments relevant to the case management of this file:

Upon submission, if you do not receive an email notification, and the notification is not in your junk or spam email folder, please contact CLRA directly.