Dmi Report Of Injury Form - 2016 Page 2

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SECTION D: SCHEDULE AND EARNINGS INFORMATION

Employment Status (check all that apply):

Permanent Full Time

Casual/Irregular

Student

Permanent Part Time

Seasonal

Registered Apprentice

Temporary Full Time

Contract

Other:

_____

__________

Temporary Part Time

Regular rate of pay $

Hour

Other:

If worker has a fixed schedule, please identify days and hours worked:

Week 1

Week 2

Fri

Sat

Fri

Sat

Sun

Mon

Tue

Wed

Thu

Sun

Mon

Tue

Wed

Thu

If not a full time employee, please identify average hours worked per week:

_____

SECTION E: RETURN TO WORK (RTW)



Has the employee returned to work?

Yes

If YES, indicate date: __________________________

To:

 Regular Duties

 Modified Duties

 Yes

 No

If NO, has the employee been provided with a written modified work offer?

 Attached

If YES to modified duties, please attach a copy of the modified work offer:

I declare all the information I have given on this report is true and correct. I understand that by completing this form, the Disability Management Institute will

submit a “Form 7” in accordance with Worker’s Compensation Act and the Occupational Health and Safety Regulations and as such, I elect to claim

compensation for the above mentioned injury(s) or disease(s), where said injury or disease has resulted in medical costs or lost time from work. I

acknowledge that the WCB may disclose information from my claim to my employer or my employer’s authorized agent for the purposes of the management

of my claim in accordance with the law including the Freedom of information and Privacy Act and the Personal Information Privacy Act. I understand it is a

serious offense to knowingly make a false claim or to work and earn income while receiving compensation without advising the WCB

Signature of Injured Employee:

Date:

Supervisor/Employer Contact:

Signature:

Date:



Do you have any concerns or relevant information regarding this claim you wish to discuss with DMI?

Yes

Comments:

Effective August 30/16