Gather this information to report your work-related injury or illness online. If you don’t have the information, you can always save your report and come back to it later.
- Injury or illness information
- Injury or illness details, including date and time. If you are reporting a mental stress or psycholgical injury, the approximate start date is okay
- Location of where injury or illness happened (e.g. construction site, customer site, in-flight, parking lot, temporary agency location)
- Date you reported the injury or illness to your employer
- Employer details, including name, address and phone number
- Work history
- Start date
- Length of time you’ve worked for your employer
- Immediate supervisors name and contact information
- Employment status (e.g., self employed, sole proprietor, partner, executive, contractor, subcontractor, piece worker, temporary agency worker etc.).
- Union name and number, if applicable
- Health care
- Details of your visit to a health care professional and their contact information
- Anticipated date of health care appointment, if you haven’t seen a health care professional
- Time off work after the day of the injury or illness, including a reduction in hours or pay
- Details about any temporary or permanent changes to your job duties, hours, or environment to allow you to work safely while recovering
- Contact information of someone we can speak with about lost time, modified work or return to work.
- Expected date of return to work, if known
- A pay stub or earnings information and frequency, including rate of pay at the time of the injury or illness. You can submit pay stub(s) for the last four weeks of pay before the date of your injury or illness to help us understand your earnings information.
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