Tribunal Ontario | WSIB: Forms – Worker’s Report of Injury/Disease (Form 6)

Worker’s Report of Injury/Disease (Form 6) – WSIB in Ontario

The Worker’s Report of Injury/Disease (Form 6) is a crucial document required by the Workplace Safety and Insurance Board (WSIB) in Ontario. It is used by workers to report any work-related injuries or diseases to ensure proper documentation and processing of claims for compensation and support. This form ensures that all necessary information is gathered to process claims efficiently and provide the required support and compensation to injured or ill workers in Ontario.

Filling out the Form 6 correctly ensures that your claim is processed efficiently. Follow this step-by-step guide to complete the form accurately.

Worker Information

• Last Name, First Name: Enter your full legal name.
• Social Insurance Number: Provide your SIN for identification purposes.
• Address: Include your complete home address (number, street, apt., suite, unit).
• Telephone & Alternate/Cell Phone: Provide your primary and alternate phone numbers.
• City/Town, Province, Postal Code: Fill in the details of your current residence.
• Job Title/Occupation: Mention your job title or occupation at the time of injury.
• Date You Started with Employer: Provide the start date in the format dd/mm/yy.
• How Long Have You Been Doing This Job for This Employer: Specify the duration in months or years.
• Additional Information
  • Executive/Elected Official/Owner/Spouse or Relative of the Employer: Check if applicable.
  • Date of Birth: Enter your birthdate in the format dd/mm/yy.
  • Sex: Indicate your sex.
  • Preferred Language: Choose your preferred language for communication (English, French, Other).
  • Interpreter Needed: Indicate if an interpreter would be helpful (yes or no).
  • Union Membership: Specify if you are a union member (yes or no). If yes, provide the union name and local number.
  • Union Representation: Indicate if you authorize your union to represent you in this claim and consent to disclosure of claim status to your union representative.

Employer Information

• Company/Employer Name: Enter the name of your employer.
• Address: Provide the complete address of your employer.
• City/Town, Province, Postal Code: Fill in the details of your employer’s location.
• Immediate Supervisor’s Name: Provide the name of your immediate supervisor.
• Company Telephone: Enter your employer’s contact number.

Accident/Illness Dates and Details

• Date and Hour of Accident/Awareness of Illness: Indicate the date and time when the accident occurred or when you became aware of the illness.
• Date and Hour Reported to Employer: Specify when you reported the accident/illness to your employer.
• Reported To: Provide the name and position of the person you reported the accident/illness to, along with their contact number.
• Area of Injury (Body Part): Check all applicable body parts affected by the injury.
• Details of Incident
  • Location: Specify if the accident happened on the employer’s property or work site and provide details.
  • Previous Injuries: Indicate if you have hurt this area(s) of your body before (yes or no).
  • Prior Claims: Mention if you have any prior related WSIB/WCB claims (no, yes in Ontario, yes outside Ontario).
  • Description: Describe how the accident/illness occurred, including the injury details, what caused it, and specifics like the size and weight of any objects involved.
  • Onset: Mention when you first started having problems with the injury/condition.
  • Reporting Delay: If you did not report the incident immediately, explain the reason.
  • Witnesses: List names and positions of any witnesses to the accident or anyone you mentioned your pain/problems to.

Health Care Information

• First Aid at Work: Indicate if you received first aid or care at work (yes or no). If yes, provide the date and the name of the person who administered it.
• External Health Care: Check all applicable places you visited for health care (facility/hospital, nursing station, emergency department, etc.) and provide the names, addresses, and dates of visits.
• Medications/Treatments: Indicate if you were prescribed any medications or referred for any other treatments or tests.
• Return to Work Discussion: Mention if you discussed returning to work with your health professional and if any work limitations were given.
• Employer Notification: State if you informed your employer about the medical treatment (yes or no). If yes, provide the date and the name/position of the person you informed.

Lost Time and Return to Work

• Return to Work Status: Specify if you returned to your regular job, modified duties, or lost time/pay. Provide relevant dates.
• Lost Time: If you lost time from work, indicate if you have returned to work (yes or no) and provide the date. Mention if it was regular or modified work.
• Return to Work Discussion: Indicate if you discussed return to work with your employer and if they have modified work available.

Earnings

• Rate of Pay: Enter your pay rate and specify if it is per hour, week, or other.
• Usual Number of Hours: Mention your usual number of work hours per week or other.
• Continuation of Pay: Indicate if your employer continued to pay you during the lost time (yes or no).
• Other Benefits: State if you applied for or received any other benefits while off work (yes or no).
• Multiple Employers: Mention if you worked for more than one employer at the time of the accident/illness (yes or no).

Declarations and Signature

• Declaration: Read the declaration carefully. By signing, you are claiming benefits and authorizing the release of information.
• Signature: Provide your signature and the date. If under 16, a parent or guardian must sign and date the form, including their relationship and telephone number.

Additional Information

• Other Relevant Information: Include any additional information you think is necessary for your claim.

Submission Instructions

• Upload: Upload the completed form and supporting documents online at wsib.ca/upload.
• Mail: Mail to 200 Front Street West, Toronto, Ontario, M5V 3J1.
• Contact: For alternative formats or assistance, contact WSIB at 1-800-387-0750.

Carefully review the form to ensure all information is accurate and complete before submitting. This helps in processing your claim smoothly and efficiently.