WCB - Worker Report of Injury or Occupational Disease

Friday October 11, 2024

Worker Report of Injury or Occupational Disease

Report Overview

Participant Details Accident Details Injury Details Return to Work Details Type of Employment Earnings Details Hours and Shift Cycle Details Other Information Submission Summary

Actions

ALERT: After 60 minutes of inactivity you will be logged out of your session and all information you've entered will be lost
NOTICE: You will have the option to Print a copy of this report at the time you submit it

Participant Details

Employer name:
Worker:		SIN:
Worker address:		Date of birth:

Employer Details




Employer name:

LABEL NOT OVERRIDEN, UPDATE CHILD
LABEL NOT OVERRIDEN, UPDATE CHILD
City:		Province:
Postal code:
Phone number:	*

Contact name:		Contact title:
Contact phone number:		Contact email address:






Worker Details
First name:		Middle name:
Last name:		Date of birth:

Mailing address:	City:
		Province:
Postal code:		Phone number:
Email address:

Alberta PHN:		SIN:
Legal gender:		Occupation:
Job description:
Date hired:
Are you an apprentice?		YesNo
Date you would have obtained journeyman status if you had not been injured:
Do you have personal coverage?		YesNo
Are you a partner or director in the business?		* YesNo

Accident Details

Injury Details

Part of body

Side of body

Nature of injury

If more than 5 parts of body, please describe any additional injuries:

Have you had a similar injury(s) before?

YesNo

Please explain:

Return to Work Details

I understand I have a duty to cooperate with WCB in arranging my safe and healthy return to work with my employer.

Have you missed work (hours or days) beyond the date of accident?

YesNo

Will your employer pay you regular pay for time missed from work?

YesNoUnknown

Date and time you first missed work:

Have you returned to work?

YesNo

Is there any work you can do until you are able to return to your regular job?

YesNo

Describe what you are capable of doing:

Has modified work been offered to you?

YesNo

Hidden

Description of modified work:

Approximate date you expect to return to work:

DateUnknown

When do you think you will be able to return to work of any kind?

Date and time you returned to work:

Are you working full hours?

YesNo

Hours worked per shift:

Are you working full duties or modified duties?

FullModified duties

Description of modified work:

Are you receiving regular/full pay or partial pay?

Regular/full payPartial pay

LABEL NOT OVERRIDEN, UPDATE CHILD

YesNo

Do you have more than one job?

YesNo

Employer Name	Phone number	Are you missing time from this job due to your injury?
Dummy content

Earnings Details

Please enter the worker's gross earnings from:
- one year prior to the date of injury,
- or from the date the worker had a change in their wages in the past year,
- or from when they had a change in jobs in the past year,
- or from the date the worker was hired if less than 1 year from the date of injury.

Entering accurate earnings information is important because the workers compensation rate will be automatically set using these earnings. If accurate earnings are not available at this time, please submit the earnings as soon as possible.

If the worker receives shift premiums, overtime, or other taxable earnings not included in the hourly rate of pay, please enter these earnings in the section(s) below.

When providing these additional earnings, please enter the gross earnings one year prior to the date of injury,
- or from the date the worker had a change in their wages in the past year,
- or from when they had a change in jobs in the past year,
- or from the date the worker was hired if less than 1 year from the date of injury.

Entering accurate earnings information is important because the workers compensation rate will be automatically set using these earnings. If accurate earnings are not available at this time, please submit the earnings as soon as possible.

Based on the information you have entered, the earnings are pro-rated to approximately annually.

Earnings Details
Rate of pay:	per
Please describe:

Do you receive any of the following:
Vacation payShift premiumOvertimeOther taxable income
Please describe:

Hours and Shift Cycle Details

Please mark regular hours not including overtime for one complete shift cycle, use zero for days off.

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Week 11
Week 12
	Note: Date of accident is highlighted in yellow.

Hours and Shift Cycle Details
Average hours per week (not including overtime):
Describe your work schedule (e.g. Monday to Friday, on. Saturday and Sunday, off.):

Other Information

Claim number:

You may attach up to file attachments to this report of type: Doc, Docx, Tif/Tiff, Pdf, Rtf, or Txt

Additional comments:

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Accident Details

Did the accident/injury develop over time? YesNo
Date/time of accident/injury:
Attention: If the exact date of accident is not known, please use the date you first missed work as a result of this injury or the date it was first reported to your Employer.
Date/time scheduled shift started:		Date/time scheduled shift ended:

Date accident/injury reported to employer:
If more than 1 week since accident/injury, explain:
To whom was the accident/injury reported:
Name:		Title:
Phone number:
Description of accident/injury:
Is this a motor vehicle accident? YesNoUnknown
If you have a Police Collision Report, please mail, email, or fax it to us as soon as you have a claim number available. Please include your name and claim number on the report. Please also complete the WCB Automobile Accident Report.
Is this a cardiac condition/injury? YesNoUnknown
Were your actions at the time of the accident/injury...
For the purpose of your employer's business? YesNoUnknown
Part of your regular work? YesNoUnknown
Did the accident/injury occur on the employer's premises? YesNoUnknown
Location of accident:
City:		Province/Territory:
Country:		Postal code:


Have you reported or claimed this accident/injury to another WCB? YesNo
Province/Territory:
When did you first seek medical treatment?
Name and location of treating doctor/hospital:
Is there any further treatment required for this injury? YesNoUnknown

Type of Employment
Please select your specific employment type from one of the 3 groupings below: *

Employed on a Permanent basis (12 Months of the year or more) in the following arrangement:
Full Time Part Time Irregular/Casual

Or, employed on a Temporary basis (position is less than 12 months per year and may be subjected to layoffs due to lack of work, shut downs, contracts or seasonal factors) in the following arrangement:
SeasonalSummer StudentTemporary
Position start date:	Position end date:		EstimatedActual
Months or days per year workers are typically employed in this position:			MonthsDays

Or, employed in a Alternate arrangement that is most accurately described as:
Sub ContractorPiece WorkVehicle Owner/OperatorWelder Owner/Operator Self EmployedVolunteerCommissionOther
Please provide additional details:
Do you incur expenses?	YesNo	Will you receive a T4?	YesNo

Message subject:
Message:
	Please include any details, such as your claim number, that would help us serve you better.
Your e-mail address:


	---------------

E-mail address:
Message subject:
	Please include as much detail as possible.
Message:


	---------------

1) General Delivery Address JOHN JONES GD STN A CALGARY AB T0H 1A0	2) Post Office Box Address JOHN JONES PO BOX 4001 STN A VICTORIA BC V8X 3X4
3) Rural Route Address JOHN JONES SITE 6 COMP 10 RR 8 STN MAIN MILLARVILLE AB T0L 1K0	4) Civic Address JOHN JONES 10-123 1/2 MAIN ST SE MONTREAL QC H3Z 2Y7


Please select the best match found:
OR Use the address as entered