Tribunal Ontario | WSIB: Forms – Worker’s Progress Report (Form 41)

Worker’s Progress Report (Form 41) – WSIB in Ontario

The “Worker’s Progress Report (Form 41)” for the Workplace Safety and Insurance Board (WSIB) in Ontario is a detailed document designed to capture the status and updates related to a worker’s injury and recovery progress. The form must be printed in black ink and can be mailed, faxed, or electronically submitted to the WSIB. It includes multiple checkboxes, text fields for detailed responses, and requires personal and claim-specific information to ensure accurate tracking and management of the worker’s progress post-injury.

To fill out Form 41 for WSIB in Ontario, follow these steps:

Claim Number: Write your WSIB claim number at the top of the form.

Worker’s Information

1. • Name: Enter your full name.
   • Original Date of Accident/Injury: Write the date when the accident or injury initially occurred.
   • Injury: Describe your injury.
   • Accident Employer Name: Provide the name of your employer at the time of the accident.

Update Information: If any of the information is incorrect, provide the updated information in the designated section.

Current Condition

1. • Check the box that best describes your current condition: Recovered, Getting Better, No Change, or Getting Worse.
   • Provide details about any changes or updates to your condition.

Primary Health Professional

1. • Name: Write the name of the primary health professional overseeing your treatment.
   • Date of Last Visit: Enter the date of your last visit to the health professional.
   • Date of Next Visit: Enter the date of your next scheduled visit.

Referrals

1. • Check the appropriate box if there are any new referrals not yet reported to WSIB: No New Referrals, Testing (e.g., labs, x-rays, CT Scan, MRI), Specialist, or Other (specify).

Medications and Assistive Devices

1. • Check ‘Yes’ or ‘No’ if you are taking any drugs/medications or using an assistive device/brace for this injury. If yes, list the names.

Employment Since Injury

1. • Check ‘Yes’ or ‘No’ if you have worked for any employer(s) or were self-employed between the first day off and now. If yes, provide details including dates and the name/address of the employer/company.

Current Employment Situation

1. • Choose the option that best describes your current situation:
     • Not lost any time or pay from work.
     • Lost time and/or pay and have returned to work.
     • Lost time and have not returned to work.

Return to Work

1. • Regular Work or Modified Work: Check the appropriate box.
   • Regular Pay or Lower Pay: Check the appropriate box.
   • Regular Hours or Less Hours: Check the appropriate box.
   • Date of Return to Work: Enter the date you returned to work.

Health Professional Discussion

1. • Check ‘Yes’ or ‘No’ if you have talked to your health professional about returning to work. If yes, provide the date of the last discussion.

Employer Discussion

1. • Check ‘Yes’ or ‘No’ if you have talked to your employer about returning to work. If yes, provide the date of the last discussion and the name of the person you talked to.

Work Limitations

1. • Check ‘Yes’ or ‘No’ if your health professional has determined your work limitations or functional abilities.

Work Offered

1. • Check ‘Yes’ or ‘No’ if any type of work has been offered to you. If yes, provide details.

Other Factors

1. • Check ‘Yes’ or ‘No’ if there are any other factors preventing you from returning to work. If yes, provide details.

Signature

1. • Sign and date the form to declare that all information provided is true.

Submission

• Mail the completed form to 200 Front Street West, Toronto ON M5V 3J1, or fax it to 416-344-4684 or 1-888-313-7373.