Wsib Form 6 - Worker'S Report Of Injury/disease Page 2
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1
2
3
4Worker's Report
6
of Injury/Disease (Form 6)
Claim Number
Please PRINT in black ink
Worker Name - Last Name
First Name
Social Insurance Number
C. Accident/Illness Dates & Details (continued)
8.
If you had a sudden type of accident/illness, describe your injury and what happened to cause it (e.g. hurt lower back while lifting a 50 pound box, sprained
left ankle when I slipped on a wet floor, used a new cleaner and immediately got a rash). Please indicate the size, weights and names of any objects involved.
or
If you had a gradual onset type of injury, describe your injury, the work that you do and what you believe caused your injury/condition.
9.
When did you first start to have problems with this injury/condition?
10.
If you did not report this to your employer right away, please tell us the reason why.
11.
If there were any witnesses to your accident, or if you mentioned your pain or problems to your supervisor or any of your co-workers,
give us their names & positions.
Name
Position
1.
2.
12.
The Workplace Safety and Insurance Act requires your employer to give you a copy of the Employer's Report of Injury/Disease (Form 7).
Did you receive a copy of the Form 7?
yes
no
The Workplace Safety and Insurance Act requires you to give a copy of this report
(Worker's Report of Injury/Disease - Form 6) to your employer.
Give your Health Professional your WSIB Claim number.
D. Health Care Information
1.
Did you get first aid
If yes, when
dd
mm
yy
and by whom (Name):
yes
no
or care at work
2.
Where did you go for health care, for your injury, outside of work? (Check all that apply)
Facility/Hospital (Name & Address)
Date of Visit (dd/mm/yy)
Nursing
Date of Visit (dd/mm/yy)
Ambulance
Station
Emergency
Health
Professional Office
Department
Admitted to
Clinic
Hospital
4.
3.
Were you referred for any other treatment or tests?
Were you prescribed any medications/drugs?
yes
no
yes
no
If yes, were you given
5.
Did you talk to your health professional about going back to
yes
no
yes
no
any work limitations?
regular or modified work?
6.
If no, please tell your employer right away.
Did you tell your employer you went for medical treatment?
yes
no
dd
mm
yy
Name
If yes, when?
and to whom?
Position
0006A (07/05)
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