Report of injury declaration and consent

To report an injury online, read the following declaration and consent statement and click the "I accept" button below.

I declare that the information I am about to provide to the Workers' Compensation Board - Alberta (WCB) in the 'Worker's Report of Injury or Occupational Disease' form will be true and correct.

I understand that:

• While I am receiving any benefits from WCB, it is my obligation to inform WCB immediately if I return to work of any kind, become capable of working or if there is any other change in my employment status. Work includes but is not limited to any activity in which labour or services are provided, whether or not payment of any kind is received.
• Criminal prosecution may result from any attempt on my part to collect benefits by providing false information, failing to provide information regarding my ability to work, or other fraudulent means.
• My employer may request a review or appeal of any decisions made on my claim and may therefore examine my claim file. My claim file may also be examined by anyone with a direct interest, as determined by WCB, or a person or company I have authorized to review my claim file. (To provide authorization, use the Worker's Information Release form).
• My social insurance number may be used for reporting to Canada Revenue Agency.
• WCB may collect information that it considers relevant to determine benefit entitlement, including information pre-dating my accident, from any source including physicians, other health care providers, employer(s) and vocational rehabilitation service providers. This information is collected to determine my entitlement to compensation under the Workers' Compensation Act.
• WCB may use and disclose the information collected to determine entitlement, to provide services and benefits and, as required or authorized by law. This information may be used and disclosed pursuant to the Workers' Compensation Act and the Access to Information Act and the Protection of Privacy Act.

NOTE: As required under subsections 4(a) and (c) of Alberta’s Protection of Privacy Act, the personal information collected in the Worker Report of Injury or Occupational Disease form is authorized by the Workers’ Compensation Act and is used for the purpose of determining entitlement to compensation and establishing employers’ premium rates. This information may also be processed by automated systems to generate content, recommendations, or predictions. Questions about the collection or use of this information may be directed to the Claims Contact Centre, as indicated on the front of this form and on the back of the Worker Handbook.