A guide for people with workplace injuries or illness
General information about the form
What is an injury or illness report?
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.
What if I need help filling out the 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.
What do I do after filling out the report?
Section A - Worker Information
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.
A1 - Date you started with your employer
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.
A2 - How long have you been doing this job for 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).
A3 - Would an interpreter be helpful?
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.
A4 – Do you authorize your union to represent you in this claim?
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.
A5 – If yes, do you consent to the disclosure of verbal claim file status information to your union representative?
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.
Section B - Employer information
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.
Section C - Accident/illness dates and details
Accident/illness dates and details
This section gives us details about your injury or illness.
C1 – Date and hour of accident/awareness of illness and date and hour reported to employer
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.
C2 – Who did you report this accident/illness to?
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.
C3 – Area of injury (body part)
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.
C4 – Did the accident/illness happen on your employer’s property or work site?
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.
C5 – Did it happen outside Ontario?
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.
C6 – Have you hurt this/these area(s) of your body before?
Check ‘yes’ if you have hurt this area before. This may help us find information for your claim.
C7 – Do you have any other related WSIB/WCB claims?
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.
C8 – If you had a sudden type of accident/illness, describe your injury…
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.
Or if you had a gradual onset type of injury, describe your injury…
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
C9 – When did you first start to have problems with this injury/condition?
We may use this information to help determine the first day of an injury or illness, especially if they develop over time.
C10 – If you didn’t report this to your employer right away, please tell us the reason why.
You should report a work-related injury or illness right away. If you didn’t, we need to know why.
C11 – If there were any witnesses to your accident …
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.
C12 – The Workplace Safety and Insurance Act requires your employer to give you a copy of the Employer’s Report of Injury/Disease (Form 7).
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.
The Workplace Safety and Insurance Act requires you to give a copy of this report (Worker’s Report of Injury/Disease – Form 6) to your employer.
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.
Section D - Health care information
Health care information
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.
D1 – Did you get first aid at work?
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.
D2 – Where did you go for health care for your injury, outside of work?
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.
D3 – Were you prescribed any medications/drugs?
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.
D4 – Were you referred for any other treatment or tests?
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.
D5 – Did you talk to your health professional about going back to regular or modified work?
Let us know if you talked to your health professional(s) about going back to work and if you were given any work limitations.
D6 – Did you tell your employer you went for medical treatment?
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.
Section E - Lost time and return to work
Lost time and return to work
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.
E1 – After the day of accident/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.
E2 – If you lost time, have you returned to work?
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.
Earnings (do not include overtime here)
This section gives us basic information about your pay. We use this information to calculate benefits for lost time from work because of your injury or illness.
F1 – Rate of pay
Tells us how much you get paid, either:
- By the hour, if you get paid hourly
- By the week, if you get paid weekly
- Other – and tell us if your pay is based on salary, commission, piecework, etc.
F2 – Usual number of pay hours:
Tell us the usual number of hours you work per week or other pay period.
F3 – If you lost time from work after the day of accident/illness, did your employer continue to pay you?
Let us know if your employer paid you for any time you missed from work because of your injury or illness.
F4 – Have you applied for, or did you receive, any other benefits (money) while off work …
You must tell us if you applied for or are getting any other benefits or money because of your injury or illness. This could be Employment Insurance (EI), sick benefits, social services, insurance, etc.
F5 – At the time of the accident/illness, did you work for more than one employer?
Tell us if you worked for more than one employer at the time you were injured or became ill. This is important when we calculate what benefits you may be entitled to.
Section G - Declarations and signature
Declarations and signature
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.
Creating an online services account
After you receive a claim number you can create an online services account to access your claim information online. Once you’ve created a profile, you can:
- view your claim status, payment, return to work and benefit details,
- submit claim documents,
- add direct deposit information, and
- send us messages.
Visit our online services FAQs to learn more.