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.
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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