Fillable Employer's Report Of Injury Disease Form 7 (WSIB)

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Employer's Report Of Injury Disease Form 7 (WSIB)

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The Employer's Report Of Injury Disease Form 7 (WSIB) form is 5 pages long and contains:

  • 0 signatures
  • 76 check-boxes
  • 277 other fields

Country of origin: CANADA
File type: PDF

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Did you know that you can
securely file your
Form 7 online?
Our online 'eForm 7' offers a fast, effective solution
for managing your Form 7 reports with the WSIB.
New features in our eForm 7 make reporting
online even quicker and easier.
To submit an eForm 7, visit our eWSIB online services
page. It only takes a few minutes to subscribe and you
can start filing your reports right away.
Please note: If you're submitting a No Lost Time
claim, only complete sections A to D, E (#1) and J.
...go to fillable PDF
Mail To:
200 Front Street West
Toronto ON M5V 3J1
OR Fax To:
416-344-4684
OR 1-888-313-7373
Toll free: 1-800-387-0750
TTY: 1-800-387-0050
wsib.ca
Employer's Report
of Injury/Disease (Form 7)
Claim Number
7
Please PRINT in black ink
A. Worker Information
Job Title/Occupation (at the time of accident/illness - do not use abbreviations)
Length of time in this position
while working for you
Social Insurance Number
Please check if this worker is a: spouse or relative of the employer
executive
elected official owner
Is the worker covered by a
Union/Collective Agreement?
Worker Reference Number
Last Name First Name
yes no
Worker's preferred language
dd mm yy
Date of
Birth
Address (number, street, apt., suite, unit)
English
French
Other
Telephone
Province
City/Town Postal Code
dd mm yy
Sex
Date of
Hire
F
M
Fold here for
#10 envelope
B. Employer Information
?
Trade and Legal Name (if different provide both)
Check
one:
Provide Number
Firm
Number
Account
Number
OR
Class/Subclass NAICS Code
Mailing Address
Telephone
City/Town Postal Code
Province
FAX Number
Description of Business Activity
Does your firm have 20 or
more workers?
yes
no
Branch Address where worker is based (if different from mailing address - no abbreviations)
City/Town Province Alternate Telephone
Postal Code
C. Accident/Illness Dates and Details
dd mm yy
1. Date and hour of
accident/Awareness
of illness
2. Who was the accident/illness reported to? (Name & Position)
AM
PM
dd mm yy
Telephone Ext.
Date and hour reported
to employer
AM
PM
3. Was the accident/illness:
4. Type of accident/illness: (Please check all that apply)
Sudden Specific Event/Occurrence Fall Slip/Trip
Struck/Caught
Gradually Occurring Over Time
Overexertion
Harmful Substances/Environmental
Motor Vehicle Incident
Occupational Disease
Repetition Assault
Fatality
Fire/Explosion
Other
5. Area of Injury (Body Part) - (Please check all that apply)
Right Right
Left Right Right
Left Left Left
Upper back
Head Teeth
Face Lower back
Neck Shoulder Wrist
Hip Ankle
Hand
Arm
Foot
Thigh
Eye(s) Chest Abdomen
Elbow Finger(s)
Ear(s) Pelvis
Toe(s)
Knee
Forearm
Lower Leg
Other
6. Describe what happened to cause the accident/illness and what the worker was doing at the time (lifting a 50 lb. box, slipped on wet floor, repetitive movements,
etc. . .). Include what the injury is and any details of equipment, materials, environmental conditions (work area, temperature, noise, chemical, gas, fumes, other
person) that may have contributed. For a condition that occurred gradually over time, please attach a description of the physical
activity required to do the work.
If you are having difficulty accessing or completing this document, please contact : accessibility@wsib.on.ca
Page 1 of 4
0007A (01/20)
A guide to complete this form is available at wsib.ca
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Page 1 of 4
Employer's Report
wsib.ca
of Injury or Illness (Form 7)
Claim Number
7
Please PRINT in black ink
Social Insurance Number
Worker Name
C. Accident/Illness Dates and Details (Continued)
Specify where (shop floor, warehouse, client/customer site, parking lot, etc..).
7. Did the accident/illness happen on the employer's
premises (owned, leased or maintained)?
yes no
If yes, where (city, province/state, country).
8. Did the accident/illness happen outside the Province
of Ontario?
yes no
If yes, provide name(s), position(s), and work phone number(s).
9. Are you aware of any witnesses or other employees
involved in this accident/illness?
1.
yes no
2.
If yes, please provide name and work phone number
10. Was any individual, who does not work for your firm,
partially or totally responsible for this
accident/illness?
yes no
If yes, please explain
11. Are you aware of any prior similar or related problem,
injury or condition?
yes no
12. If you have concerns about this claim, attach a written submission to this form.
submission attached
D. Health Care
dd yy dd yy
mm mm
2. When did the employer learn that the worker
received health care?
1. Did the worker receive health care for this injury?
yes no If yes, when :
3. Where was the worker treated for this injury? (Please check all that apply)
On-site health care Ambulance Emergency department Admitted to hospital Health professional office Clinic
Other:
Name, address and phone number of health professional or facility who treated this worker (if known).
E. Lost Time - No Lost Time
1. Please choose one of the following indicators. After the day of accident/awareness of illness, this worker:
Returned to his/her regular job and has not lost any time and/or earnings. (Complete sections G and J).
Returned to modified work and has not lost any time and/or earnings. (Complete sections F, G, and J).
Has lost time and/or earnings. (Complete ALL remaining sections).
dd yy dd yy
mm mm
regular work
Provide date worker first lost time Date worker returned to work (if known)
υ
υ
modified work
2. This Lost Time - No Lost Time - Modified Work information was confirmed by:
Telephone Ext.
Myself
Other
Name
F. Return To Work
2. Has modified work been
discussed with this worker?
3. Has modified work been
offered to this worker?
If yes, was it
1. Have you been provided with work
limitations for this worker's injury?
Accepted
Declined
If Declined please attach a copy of
the written offer given to the worker.
yes no yes no yes no
4. Who is responsible for arranging worker's return to work
Telephone Ext.
Other
Myself
Name
Page 2 of 4
0007A (01/20)
Start >
Page 2 of 4
Employer's Report
of Injury/Disease (Form 7)wsib.ca
Claim Number
7
Please PRINT in black ink
Worker Name Social Insurance Number
G. Base Wage/Employment Information - (Do not include overtime here)
1. Is this worker (Please check all that apply)
Owner Operator or
(Sub) Contractor
Casual/Irregular Registered Apprentice
Permanent Full Time Student
Permanent Part Time
Seasonal
Unpaid/Trainee Optional Insurance
Temporary Full Time
Contract
Other
Temporary Part Time
2. Regular rate of pay
$
per hour day week other
H. Additional Wage Information
Provide
percentage
1. Net Claim Code
or Amount
2. Vacation pay
- on each cheque?
%
Federal Provincial
yes no
3. Date and hour last worked 4. Normal working hours on
last day worked
5. Actual earnings for
last day worked
6. Normal earnings for
last day worked
dd mm yy
From
To
AM
AM AM
$
$
PM
PM PM
7. Advances on wages:
Is the worker being paid while he/she recovers?
yes no Full/Regular Other
If yes, indicate:
8. Other Earnings (Not Regular Wages): Provide the total of additional earnings for each week for the 4 weeks before the accident/illness.
* For Rotational Shift workers - If the shift cycle exceeds 4 weeks,
please attach the earnings information for the last complete shift
cycle prior to the date of accident/illness.
Use these spaces for any other earnings
(indicate Commission, Differentials, Premiums,
Bonus, Tips, In Lieu %, etc..).
θ
Mandatory
Overtime Pay
Voluntary
Overtime Pay
From Date
(dd/mm/yy)
To Date
(dd/mm/yy)
Period
$ $ $ $ $ $
Week 1
Week 2
$ $ $ $ $ $
$ $ $ $ $ $
Week 3
Week 4 $ $ $ $ $ $
I. Work Schedule (Complete either A, B or C. Do not include overtime shifts)
Example: Monday to Friday, 40 hours
(A.) Regular Schedule - Indicate normal work days and hours.
υ
S M T W T F S
Sunday
Monday Tuesday Wednesday Thursday Friday Saturday
8 8 8 8 8
or,
(B.) Repeating Rotational Shift Worker - Provide
NUMBER OF
DAYS ON
NUMBER OF
DAYS OFF
HOURS
PER SHIFT(s)
NUMBER OF WEEKS
IN CYCLE
Example: 4 days on, 4 days off, 12 hours per shift, 8 weeks in cycle.
υ
or,
- Provide the total number of regular hours and shifts for each week for the 4 weeks
prior to the accident/illness. (Do not include overtime hours or shifts here).
(C.) Varied or Irregular Work Schedule
Week 3
Week 4
Week 1 Week 2
From/To Dates (dd/mm/yy)
Total Hours Worked
Total Shifts Worked
J. 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.
Name of person completing this report (please print) Official title
dd yy
mm
Signature Telephone Ext. Date
THE WORKPLACE SAFETY AND INSURANCE ACT REQUIRES YOU GIVE A COPY OF THIS FORM TO YOUR WORKER
Page 3 of 4
0007A (01/20)
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Commission
Commission
Commission
Commission
/
/
/
/
Type your name and upload, or print and sign before returning to WSIB.
Page 3 of 4
Employer's Report
of Injury/Disease (Form 7)wsib.ca
Claim Number
7
Please PRINT in black ink
Worker Name Social Insurance Number
K. Additional Information
THE WORKPLACE SAFETY AND INSURANCE ACT REQUIRES YOU GIVE A COPY OF THIS FORM TO YOUR WORKER
0007A (01/20) Page 4 of 4
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Employer's Report Of Injury Disease Form 7 (WSIB)

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Completed 17 January 2022

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