An injury or illness report is a WSIB form that you fill out and send to us after you are injured or become ill at work. It’s a way for you to tell us what happened to cause the injury or illness. It also gives us information we need to process and make decisions about your claim. This form is different from the one you may have filled out at work for your employer. 

When you complete and send us this form, you are making a claim for WSIB benefits. You must file a claim within six months of an injury or within six months of an occupational disease diagnosis.

For more information about the WSIB and the services we provide, check out Your Guide.

There are several ways to get this form: 

• find it in the forms section of the website, fill it out and submit it online
• your local union office/representative may have one to give you
• call or drop by your local WSIB office and ask for an injury or illness report

If you need help or can’t complete the report yourself, we suggest that first you ask a family member or friend to help you. You can also call us at 1-800-387-0750 from Monday to Friday, 7:30 a.m. to 7:45 p.m. If you are deaf or hard of hearing, call TTY: 1-800-387-0050.

You should submit it online. 

Remember to give a copy to your employer and keep a copy for your own records. Please print clearly in black ink.

Please make sure all information is complete and correct. Incorrect information may cause delays in handling your claim. Make sure you include your:

• full name
• complete mailing address
• phone number
• date of birth, and
• Social Insurance Number.

Please note you must put your name and Social Insurance Number on all three pages.

Give us the date that you started to work with your employer. If you worked for them in the past (for example if you are a temporary or seasonal worker), give us the most recent (latest) date that you started to work with this employer.

Give the length of time (in years, months, weeks or days) that you were doing your job before your injury or illness. 
For example, you worked for ABC Company for six years, first as shipper/receiver for two years, then as warehouse lead hand for one year, then as warehouse manager for three years. You were a manager when injured, so put the length of time were a manager (three years).

Select ‘yes’ if you would like to use our free translation and interpretation services. To ask for help in another language, call 1-800-465-5606.

If you are a member of a union, you may want to contact them to help you with your claim. If you do want them to represent you, please check ‘yes’ here.

This means you agree to let the WSIB talk about your claim with your union representative. If you do want your union to help you with this claim, check ‘yes’ here so we can talk to them about it. If your union representative wants access to written material in your claim, you must also send us a direction of authorization form. You can submit this form at the same time you submit your report. If you choose to have a representative but they are not from your union, you will still need to fill out a direction of authorization form.

This section gives us information about your employer. We need all the information listed. We use it to make decisions in your claim and to contact your employer if necessary. If you need to, check your pay stub for the right information, including the full company name. If you work for a temporary employment agency, please give us the name of the agency who sent you to the job, not the name of the worksite employer. You can give us information about where the injury or illness happened in the next section.

This section gives us details about your injury or illness.

If the injury happened suddenly (e.g., you slip on a wet floor and twist your left ankle), give us the date and time it happened. If it didn’t happen suddenly, but happened over time (e.g., as a cashier, you develop tennis elbow because of scanning groceries) give us the approximate date you first noticed it.
Give us the date and time you first told your employer about the injury or illness. Remember, it’s important to let them know right away.

Give the name, title and phone number of the person you reported it to. This person should be your supervisor, manager, company nurse, or another person representing your employer.

Check boxes for all the body parts you may have injured. If it’s not listed here, check “other” and describe the body part. Tell us if it’s the left or right side of your body.

Tell us where it happened at work (shop floor, warehouse, client/customer site, parking lot, shipping area, etc.).If it didn’t happen on your employer’s property or work site, tell us where it happened. For example, if you do cleaning work at different places, name the place and location. If you work for a temporary employment agency, put the name of the company where you were placed.

If yes, you may have the choice to claim benefits in Ontario, or in the place where it happened. 
For example, if a truck driver lives in Ontario, but has an accident in Manitoba, they may choose to make a claim in Manitoba or Ontario.
If this happens, we’ll mail you a form to choose where you want to claim benefits. If you want to claim in Ontario, you must say so on the form. Without your choice, we can set up a claim, but we can’t make any decisions until we get the form. You have three months from the date we send the form to send it back to us.

Check ‘yes’ if you have hurt this area before. This may help us find information for your claim. 

If you’ve had a claim for the same injury or injury to the same area of the body before, let us know. This helps us decide if this may be a re-injury under a previous claim instead of a new one. WCB claims are older ones from when WSIB was called the Workers’ Compensation Board.

Tell us in detail how the injury or illness happened and what you were doing. Tell us the size and weight of any items and describe any machines, tools or vehicles you were using. Let us know about any temperature changes, noise, chemicals, gas or fumes. Tell us if another person was involved.

For example, I was moving boxes to a storage room. I lifted a 40 lb box from the floor to put it on a shelf. I twisted to the right while lifting and I hurt my upper back.

If your injury or illness happened over time, tell us about the work you do. Describe:

• How often you do this work
• The sizes and weight of anything you lift
• How long you have been doing this work 
• If anything about the work or your schedule changed
• Any tools or things you use to do this work

We may use this information to help determine the first day of an injury or illness, especially if they develop over time.

You should report a work-related injury or illness right away. If you didn’t, we need to know why.

Tell us the names and titles of any coworkers you told about the accident, or who may have seen it happen. We may need to talk to them to get more information.

Let us know if your employer gave you a copy of their report of the injury or illness. If they didn’t, ask them for your copy.

You must also give your employer a copy of your report. The information may help them understand what happened, and help make sure it doesn’t happen again.

If you get health care for your injury or illness, you must tell the person treating you that the injury happened at work. They will fill out a report and send it to us so you can make a claim for benefits. As soon as you know your claim number, give it to the person treating you.

First aid means any care that a trained first aider could give – even if done by a health care professional at your work. Check ‘yes’ if someone treated you at work. Tell us the date you were treated, and the name of person who treated you.

Health care means any treatment by a registered health care professional, like a chiropractor, physician, physiotherapist, registered nurse extended class or dentist. This could be at a hospital, an office, a clinic, etc. Check all the places you got health care outside of work.

Let us know if you received any medication or drugs for your injury or illness. We may pay for medication as part of your benefits. You do not need to give the name of the medication.

Let us know if you were referred for any other treatment, like physiotherapy, chiropractic treatment, massage, or any tests like a MRI, CT scan, or x-ray.

Let us know if you talked to your health professional(s) about going back to work and if you were given any work limitations. 

You must tell your employer when you get medical treatment for your injury or illness. Tell us the date you told your employer that you got treatment. If they haven’t already, they need to fill out and send us an Employer’s Report of Injury/Disease (Form 7). If you haven’t told them, please tell them right away.

This section tells us if you lost time and/or pay because of your injury or illness. If you did lose time and went back to work, we need information about your return to work. If you have not gone back to work, you need to talk to your employer about going back to work.
Your employer must pay you your full wages for the day of your injury or illness.

I returned to work to my regular job and did not lose any time or pay.

Check this box if you went back to your next regular scheduled shift and your normal work duties with no changes and you did not miss any time for work or lose any pay.

I returned to modified duties and did not lose any time or pay

Check this box if you went back to your next regular scheduled shift and you did modified or different work duties and you did not miss any time from work or lose any pay. Modified work can be any change or accommodation to your work or your workplace.

I lost time and/or pay.

Check this box if you missed any time from work or lost any pay or your employer paid you while you were off work. You may have been off for part of a day or a full day or more. Or you may have took time off for a medical appointment or health care for your injury or illness.

Date you first lost time and/or pay.

Give us the first date that you missed work or that you lost any pay.

If yes, provide the date of your return 

Check ‘yes’ if you lost time after your injury or illness, but have since gone back to work. Give us the date you went back to work, and tell us if it was your regular work, or if it was modified or different work.

If no, did you discuss your return to work with your employer?

Check ‘no’ and let us know if you’ve talked to your employer about getting back to work yet. You must talk to your employer about your return to regular or modified work. 

Does your employer have modified work?

It is your responsibility to call your employer to find out if they have work you can do while recovering. If there is any change in your work after you send us this report, call us right away and let us know what has changed.

Please sign, date the form, and submit it online. 

When you sign this form, you declare all the information on each page is true. If you don’t sign the form, it could delay your claim processing. By signing, you also give the health professional treating you consent to give you, your employer and the WSIB information about your functional abilities. This is important when planning for your safe return to work.

Your privacy is important to us. Learn more about how we protect your privacy and the confidentiality of your personal information.