Mail To:
Workplace Safety and
Insurance Board
200 Front Street West
Toronto ON M5V 3J1
OR Fax To:
416-344-4684
OR 1-888-313-7373
Worker's Report
of Injury/Disease (Form 6)
Claim Number
6
Please PRINT in black ink
A. Worker Information
Social Insurance Number
First Name
Last Name
Telephone
Address (number, street, apt., suite, unit)
Alternate/Cell Phone
City/Town Province Postal Code
dd mm yy
Job Title/Occupation (at the time you were hurt)
How long have you
been doing this job
for this employer?
Date you
started
with employer
dd mm yy
Only check if you
are one of the following:
Date of
Birth
executive elected official owner spouse or relative of the employer
Your Preferred Language
Sex
Would an interpreter
be helpful?
yes
no
Other
F English French
M
Are you a member of a union? Do you authorize your union to represent you
in this claim?
If yes, do you consent to the disclosure of verbal claim
file status information to your union representative?
yes
no
yes
no yes no
Provide your Union Name and Local
B. Employer Information
Company/Employer Name
Address
Postal Code
City/Town Province
Your Immediate Supervisor's Name
Company Telephone
C. Accident/Illness Dates & Details
dd mm yy
2. Who did you report this accident/illness to? (Name & Position)
1. Date and hour
of accident/Awareness
of illness
AM
PM
Telephone
dd mm yy
Date and hour reported
to employer
AM
PM
3. Area of Injury (Body Part) - (Please check all that apply)
Right Right
Left Right Right
Left Left Left
Upper back
Head Teeth
Shoulder Wrist
Hip Ankle
Lower back
Face Neck
Hand
Arm
Foot
Thigh
Eye(s) Chest
Abdomen
Elbow Finger(s)
Toe(s)
Knee
Pelvis
Ear(s)
Forearm
Lower Leg
Are you:
Other: Left Handed
Right handed
Specify where it happened (shop floor, warehouse, client/customer site, parking lot, etc.):
4. Did the accident/illness happen on
the employer's property or work site?
yes no
If yes, indicate where
(city, province/state, country):
5. Did it happen outside the Province
of Ontario?
yes no
7. Do you have any prior
related WSIB/WCB claims?
6. Have you hurt this area(s) of your
body before?
yes no
no yes - In Ontario yes - Outside Ontario
A guide to complete this form is available at www.wsib.on.ca
0006A (09/15) Page 1 of 3
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University of Guelph
50 Stone Road
Guelph
ON
N1G 2W21
519
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Worker's Report
of Injury/Disease (Form 6)
Claim Number
6
Please PRINT in black ink
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
dd mm yy
and by whom (Name):
1. Did you get first aid
or care at work
If yes, when
yes no
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
Station
Date of Visit (dd/mm/yy)
Ambulance
Emergency
Department
Health
Professional Office
Admitted to
Hospital
Clinic
4. Were you referred for any other treatment or tests?
3. Were you prescribed any medications/drugs?
yes no yes no
If yes, were you given
any work limitations?
5. Did you talk to your health professional about going back to
regular or modified work?
yes no
yes no
If no, please tell your employer right away.
6. Did you tell your employer you went for medical treatment?
yes no
dd mm yy
Name
If yes, when? and to whom?
Position
0006A2 Page 2 of 3
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Worker's Report
of Injury/Disease (Form 6)
Claim Number
6
Please PRINT in black ink
Last Name First Name
Social Insurance Number
E. Lost Time & Return to Work
1. 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.).
dd mm yy
Date you first lost time and/or pay
2. If you lost time, have you returned to work?
yes no
dd mm yy
Date of your return to work
If yes
regular work modified work
Does your employer have modified work?
Did you discuss return to work with
your employer?
If no
yes no
yes no
F. Earnings (Do not include overtime here)
1. Rate of pay:
per hour week other:
$
2. Usual number of pay hours:
per week other:
3. If you lost time from work after the day of accident/illness, did your employer continue to pay you? yes no
4. Have you applied for, or did you receive, any other benefits (money) while off work
(e.g. EI benefits, sick benefits, social services, insurance, etc.).
yes no
5. At the time of the accident/illness did you work for more than one employer?
no
yes
G. Declarations and Signature
By signing below, I am claiming benefits under the Workplace Safety and Insurance Act, 1997, for a work-related injury or disease. I am also authorizing any health
professional who treats me to provide me, my employer and the Workplace Safety and Insurance Board with information about my functional abilities on the WSIB's
"Functional Abilities Form for Planning Early and Safe Return to Work".
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)
If you are under the age of 16, your parent or guardian, must authorize the release of the functional abilities information.
Date (dd/mm/yy) Telephone
Signature
Relationship:
( )
Personal information about you will be collected throughout your claim under the authority of the Workplace Safety and Insurance Act, 1997. Your personal information
will be used to administer your claim(s) and programs of the Board. Medical and non-medical information is collected from health care providers, vocational agencies,
labour market service providers, employers, witnesses, Canada Revenue Agency (CRA), and others as required. Your Social Insurance Number is used to register claims,
identify workers and to issue income tax statements and is collected under the authority of the Income Tax Act. Information may only be disclosed to the employer,
external medical consultants, external service providers, researchers, third parties for cost recovery purposes 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 parties conducting satisfaction
surveys and focus groups. Incoming and outgoing calls may be recorded for quality assurance purposes. Questions about this collection should be directed to the
decision maker responsible for your file or by calling 1-800-387-0750.
A more detailed PRIVACY STATEMENT for workers may be found at www.wsib.on.ca or by calling toll free at 1-800-387-0750.
0006A3 Page 3 of 3
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Type your name and upload, or print and sign before returning to WSIB
Type your name and upload, or print and sign before returning to WSIB
Worker's Report
of Injury/Disease (Form 6)
Claim Number
6
Please PRINT in black ink
Social Insurance Number
First Name
Last Name
K. Additional Information
The Workplace Safety & Insurance Act requires you to give a copy of this report
(Worker's Report of Injury/Disease - Form 6) to your employer
0006A4
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