Wsib Form 6 - Worker'S Report Of Injury/disease Page 3

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Worker's Report

of Injury/Disease (Form 6)

Claim Number

Please PRINT in black ink

Worker Name - Last Name

First Name

Social Insurance Number

E. Lost Time & Return to Work

After the day of accident/illness:

I returned to work to my regular job and did not lose any time or pay.

I returned to modified duties and did not lose any time or pay.

I lost time and/or pay (e.g. regular pay, shift differential, bonuses, premiums, etc.).

Date you first lost time and/or pay

If you lost time, have you returned to work?

yes

Date of your return to work

yes

regular work

modified work

Did you discuss return to work with

Does your employer have modified work?

yes

your employer?

F. Earnings (Do not include overtime here)

Rate of pay:

per

hour

week

other:

Usual number of pay hours:

per

week

other:

If you lost time from work after the day of accident/illness, did your employer continue to pay you?

yes

Have you applied for, or did you receive, any other benefits (money) while off work

yes

(e.g. EI benefits, sick benefits, social services, insurance, etc.).

At the time of the accident/illness did you work for more than one employer?

yes

G. Declarations and Signature

By signing below, you are claiming benefits under the Workplace Safety and Insurance Act, 1997, for a work-related injury or disease. When you make a claim for

benefits, you must consent to disclose your functional abilities information. Your consent allows your health professional to release information about your functional

abilities directly to your employer in addition to the WSIB.

It is an offence to deliberately make false statements to the Workplace Safety and Insurance Board.

I declare that all of the information provided on pages 1, 2, and 3 is true.

Signature

Date (dd/mm/yy)

Please print form & sign before returning to the WSIB

If you are under the age of 16, your parent or guardian, must authorize the release of the functional abilities information.

Signature

Relationship:

Date (dd/mm/yy)

Telephone

(

)

Please print form & sign before returning to the WSIB

Personal information about you will be collected throughout your claim under the authority of the Freedom of Information and Protection of Privacy Act and

will be used to administer the Workplace Safety and Insurance Act, 1997, your claim and programs of the Board. Medical and non-medical information is

collected from health care providers, vocational agencies, labour market service providers, employers, witnesses, and others as required. Your Social

Insurance Number is used to register claims, identify workers and to issue income tax receipts and is collected under the authority of the Income Tax Act.

Information may only be disclosed to the employer, external medical, vocational, and safety agencies, external payment and service providers, researchers,

and others as authorized by the Workplace Safety and Insurance Act and the Freedom of Information and Protection of Privacy Act. Your name and telephone

number may be disclosed to third party researchers conducting satisfaction surveys and focus groups. Questions should be directed to the decision maker

responsible for your file or toll free at 1-800-387-5540.

A more detailed PRIVACY STATEMENT for workers may be found at

or by calling toll free at 1-800-387-5540.

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