Belte r r a Cor p or at ion S afety M an ual D oc I D C H S M BE L 2 0 1 7 Pa g e 4 97 of 53 8 E M PL OYER R ESP ON SE T O W OR K ER R I GH T T O R EF U SE N OT I F I C A T I ON Doc u m e n t Identif icat ion F R M 029 P age Nu m b e r 1 of 1 Doc u m e n t C r e ation Dat e J a nua r y 1 2013 Im p le m e n tat ion Dat e J a nua r y 1 2013 This docume nt m ust be a c c o mpanie d b y a c ompl e ted W orke rs R ig ht t o R e f use Notific a ti on to Em plo y e r F o rm R e porte d b y Oc c upa ti on R e porte d to P osit ion Da te r e po rte d L oc a ti on De sc riptio n of n oti fic a ti o n De sc riptio n of a c ti vit ies le a din g up to not ific a ti on W ha t fa c tors c ontribut e d to t he noti fic a ti on W ha t i s the pr oba bil it y o f r e c u rr e n c e F r e q ue nt Oc c a sional R a re W ha t ac ti ons ha ve or w il l be ta ke n I nv e sti ga ti ng man a g e r Da te F il e c losed b y Da te Ma na g e ment si g na tur e Da te