Worker forms
Categories:
| Form Number | Form Name |
|---|---|
| Report An Injury/Illness | |
| 0006A (337k, pdf) |
Worker's Report of Injury/Disease Form 6 The Reference Guide for Workers (1.3mb, pdf) will give you more information on filling out this form. |
| 0032A (265k, pdf) |
Worker's Report Occupational Noise Induced Hearing Loss |
| 3958A (276k, pdf) |
Worker's Exposure Incident Reporting Form - PEIR
|
| 3885A (1.6mb, PDF) |
Worker's Exposure Incident Reporting Form - CEIR
|
| Claims | |
New2397A (86.0kb, PDF) |
Intent to Object formRead our instructions to workers (81.4kb, PDF) on how to fill out this form. |
|
(148k, pdf) |
WSIB Medication Reimbursement Form |
| 1087A (165k, pdf) |
Voluntary X-Ray & Pulmonary Function Test |
| 2144A (48k, pdf) |
Request a copy of your claim form (Request for Access to Own Personal Information) |
| 2721A (198k, pdf) |
Worker Travel Expense Form |
| 2996A (79.5kb, PDF) | Work Transition: Worker Travel and Expenses |
| 3164A (324k, pdf) |
General Worker Expense Form |
| 3306A (159.9kb, PDF) | Clothing allowance application |
| 3585A (352k, pdf) |
Vision Care Claim Form |
| Employee Coverage | |
| 2929A (228k, pdf) |
WSIB Policy Manuals/Newsletter Order Form |
| 1824A (128k, pdf) |
Direction of Authorization This is not a request for access or an appeals form. It is only used to provide authorization for representation in a claim. Only after this authorization is obtained can a representative be given verbal or written information about the claim or make a request to be provided with copies of claim file documents. |
| Return to Work and Recovery | |
| 0041A (194k, pdf) |
Worker's Progress Report |
| 2232A (236k, pdf) |
Worker's Continuity Report (Form REO6) |
| 2647A (147.0kb, PDF) |
Functional Abilities Form for Early and Safe Return to Work version 2006 Guide to Completing the Functional Abilities Form (239k, pdf) Old version (November 2000) of Functional Abilities Form for Timely Return to Work (187k, pdf, view only; Worker's Health number & Social Insurance number not required on form) |
| Health and Safety | |
| 3189A (276k, pdf) |
Workplace-Specific Hazard Training Confirmation |
