WSIB Form 6 "Worker's Report of Injury/Disease" - Ontario, Canada

What Is WSIB Form 6?

WSIB Form 6, Worker's Report of Injury/Disease, is a formal document Ontario residents complete to describe the details of an injury or illness that has occurred while they were working. The employer must submit WSIB Form 7, Employer's Report of Injury/Disease, to the Ontario Workplace Safety and Insurance Board (WSIB) - they will accept the claim and assign a number to it. Then, the employee has to compose the report to inform the authorities about the incident and immediate or subsequent medical care they have received in their own words.

Alternate Name:

  • WSIB Claim Form 6.

This document was released on September 1, 2015, with all previous editions obsolete. Download a WSIB Form 6 fillable version through the link below.

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How to Fill Out WSIB Form 6?

Follow these steps to prepare WSIB Claim Form 6:

  1. Write down the claim number and indicate your personal information - full name, social insurance number, date of birth, sex, preferred language. Add your telephone number and address and describe your job position. If you are an executive, owner, elected official, or a family member of the employer, check the appropriate box. If you belong to a union, check the boxes to request its representation.
  2. Name the employer and your immediate supervisor and add the contact information of the company you work for.
  3. Describe the illness or injury - state the timeline, name the individual you reported the issue to, check the boxes to specify which body part was harmed, and describe the location of the incident. Use free space to list the specifics of the disease or accident and outline any further problems you have encountered if they are related to the incident. If you have filed any WSIB claims in the past, answer "yes."
  4. State what kind of medical help you have received - first aid, hospital admission, medical appointments, etc. Confirm your employer knows you have sought medical care and check the boxes to show you have been prescribed medications or referred for additional treatment.
  5. If you have lost any time due to the incident, write down when you have returned to work and explain whether you have discussed the return or modification to your duties with the company.
  6. State your usual rate of pay and the number of hours per week. Certify whether you have received any benefits while you were unable to work and whether you have been employed elsewhere.
  7. Sign and date the document. If you are younger than sixteen, the document must also have the signature and telephone number of your parent or legal guardian who gives their permission to submit a claim.
  8. Enter your full name and social insurance number on every page of the form. In case you have additional information you would like to share, use the last page of the document. The original report must be sent to the WSIB in a paper form, and do not forget to give a copy to your employer.
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6
Worker's Report
Mail To:
OR Fax To:
of Injury/Disease (Form 6)
Workplace Safety and
416-344-4684
Insurance Board
OR 1-888-313-7373
200 Front Street West
Claim Number
Toronto ON M5V 3J1
Please PRINT in black ink
print
reset
save
A. Worker Information
First Name
Social Insurance Number
Last Name
start >
Telephone
Address (number, street, apt., suite, unit)
City/Town
Province
Postal Code
Alternate/Cell Phone
Job Title/Occupation (at the time you were hurt)
dd
mm
yy
How long have you
Date you
been doing this job
started
with employer
for this employer?
dd
mm
yy
Only check if you
Date of
executive
elected official
owner
spouse or relative of the employer
are one of the following:
Birth
Sex
Your Preferred Language
Would an interpreter
yes
no
M
F
English
French
Other
be helpful?
Are you a member of a union?
Do you authorize your union to represent you
If yes, do you consent to the disclosure of verbal claim
yes
no
in this claim?
file status information to your union representative?
yes
no
yes
no
Provide your Union Name and Local
B. Employer Information
Company/Employer Name
Address
City/Town
Province
Postal Code
Your Immediate Supervisor's Name
Company Telephone
C. Accident/Illness Dates & Details
dd
mm
yy
2.
1.
Who did you report this accident/illness to? (Name & Position)
Date and hour
AM
of accident/Awareness
PM
of illness
Telephone
dd
mm
yy
Date and hour reported
AM
to employer
PM
3.
Area of Injury (Body Part) - (Please check all that apply)
Right
Right
Left
Left
Left
Right
Left
Right
Upper back
Head
Teeth
Shoulder
Wrist
Hip
Ankle
Lower back
Face
Neck
Hand
Arm
Thigh
Foot
Eye(s)
Chest
Abdomen
Elbow
Finger(s)
Knee
Toe(s)
Ear(s)
Pelvis
Forearm
Lower Leg
Are you:
Other:
Left Handed
Right handed
4.
Specify where it happened (shop floor, warehouse, client/customer site, parking lot, etc.):
Did the accident/illness happen on
yes
no
the employer's property or work site?
5.
If yes, indicate where
Did it happen outside the Province
yes
no
(city, province/state, country):
of Ontario?
7.
6.
Do you have any prior
Have you hurt this area(s) of your
yes
no
no
yes - In Ontario
yes - Outside Ontario
related WSIB/WCB claims?
body before?
A guide to complete this form is available at www.wsib.on.ca
0006A (09/15)
Page 1 of 3
next page
6
Worker's Report
Mail To:
OR Fax To:
of Injury/Disease (Form 6)
Workplace Safety and
416-344-4684
Insurance Board
OR 1-888-313-7373
200 Front Street West
Claim Number
Toronto ON M5V 3J1
Please PRINT in black ink
print
reset
save
A. Worker Information
First Name
Social Insurance Number
Last Name
start >
Telephone
Address (number, street, apt., suite, unit)
City/Town
Province
Postal Code
Alternate/Cell Phone
Job Title/Occupation (at the time you were hurt)
dd
mm
yy
How long have you
Date you
been doing this job
started
with employer
for this employer?
dd
mm
yy
Only check if you
Date of
executive
elected official
owner
spouse or relative of the employer
are one of the following:
Birth
Sex
Your Preferred Language
Would an interpreter
yes
no
M
F
English
French
Other
be helpful?
Are you a member of a union?
Do you authorize your union to represent you
If yes, do you consent to the disclosure of verbal claim
yes
no
in this claim?
file status information to your union representative?
yes
no
yes
no
Provide your Union Name and Local
B. Employer Information
Company/Employer Name
Address
City/Town
Province
Postal Code
Your Immediate Supervisor's Name
Company Telephone
C. Accident/Illness Dates & Details
dd
mm
yy
2.
1.
Who did you report this accident/illness to? (Name & Position)
Date and hour
AM
of accident/Awareness
PM
of illness
Telephone
dd
mm
yy
Date and hour reported
AM
to employer
PM
3.
Area of Injury (Body Part) - (Please check all that apply)
Right
Right
Left
Left
Left
Right
Left
Right
Upper back
Head
Teeth
Shoulder
Wrist
Hip
Ankle
Lower back
Face
Neck
Hand
Arm
Thigh
Foot
Eye(s)
Chest
Abdomen
Elbow
Finger(s)
Knee
Toe(s)
Ear(s)
Pelvis
Forearm
Lower Leg
Are you:
Other:
Left Handed
Right handed
4.
Specify where it happened (shop floor, warehouse, client/customer site, parking lot, etc.):
Did the accident/illness happen on
yes
no
the employer's property or work site?
5.
If yes, indicate where
Did it happen outside the Province
yes
no
(city, province/state, country):
of Ontario?
7.
6.
Do you have any prior
Have you hurt this area(s) of your
yes
no
no
yes - In Ontario
yes - Outside Ontario
related WSIB/WCB claims?
body before?
A guide to complete this form is available at www.wsib.on.ca
0006A (09/15)
Page 1 of 3
next page
6
Worker's Report
of Injury/Disease (Form 6)
Claim Number
Please PRINT in black ink
Last Name
First Name
Social Insurance Number
C. Accident/Illness Dates & Details (continued)
8.
If you had a sudden type of accident/illness, describe your injury and what happened to cause it (e.g. hurt lower back while lifting a 50 pound box, sprained
left ankle when I slipped on a wet floor, used a new cleaner and immediately got a rash). Please indicate the size, weights and names of any objects involved.
or
If you had a gradual onset type of injury, describe your injury, the work that you do and what you believe caused your injury/condition.
start >
9.
When did you first start to have problems with this injury/condition?
10.
If you did not report this to your employer right away, please tell us the reason why.
11.
If there were any witnesses to your accident, or if you mentioned your pain or problems to your supervisor or any of your co-workers,
give us their names & positions.
Name
Position
1.
2.
12.
The Workplace Safety and Insurance Act requires your employer to give you a copy of the Employer's Report of Injury/Disease (Form 7).
Did you receive a copy of the Form 7?
yes
no
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.
Give your Health Professional your WSIB Claim number.
D. Health Care Information
1.
yes,
dd
mm
yy
and by whom (Name):
Did you get first aid
If
when
yes
no
or care at work
2.
(Check all that apply)
Where did you go for health care, for your injury, outside of work?
Facility/Hospital (Name & Address)
Date of Visit (dd/mm/yy)
Nursing
Date of Visit (dd/mm/yy)
Ambulance
Station
Emergency
Health
Professional Office
Department
Admitted to
Clinic
Hospital
4.
3.
Were you referred for any other treatment or tests?
Were you prescribed any medications/drugs?
yes
no
yes
no
yes,
5.
If
were you given
Did you talk to your health professional about going back to
yes
no
yes
no
any work limitations?
regular or modified work?
If no, please tell your employer right away.
6.
Did you tell your employer you went for medical treatment?
yes
no
dd
mm
yy
Name
yes,
If
when?
and to whom?
Position
0006A2
Page 2 of 3
next page
6
Worker's Report
of Injury/Disease (Form 6)
Claim Number
Please PRINT in black ink
Last Name
First Name
Social Insurance Number
E. Lost Time & Return to Work
1.
After the day of accident/illness:
regular job
did not
I returned to work to my
and
lose any time or pay.
start >
modified duties
did not
I returned to
and
lose any time or pay.
lost time and/or pay
I
(e.g. regular pay, shift differential, bonuses, premiums, etc.).
dd
mm
yy
Date you first lost time and/or pay
2.
If you lost time, have you returned to work?
yes
no
dd
mm
yy
yes
Date of your return to work
If
regular work
modified work
Did you discuss return to work with
Does your employer have modified work?
no
If
yes
no
yes
no
your employer?
F. Earnings (Do not include overtime here)
1.
Rate of pay:
per
hour
week
other:
$
2.
Usual number of pay hours:
per
week
other:
3.
If you lost time from work after the day of accident/illness, did your employer continue to pay you?
yes
no
4.
Have you applied for, or did you receive, any other benefits (money) while off work
yes
no
(e.g. EI benefits, sick benefits, social services, insurance, etc.).
5.
At the time of the accident/illness did you work for more than one employer?
yes
no
G. Declarations and Signature
By signing below, I am claiming benefits under the Workplace Safety and Insurance Act, 1997, for a work-related injury or disease. I am also authorizing any health
professional who treats me to provide me, my employer and the Workplace Safety and Insurance Board with information about my functional abilities on the WSIB's
"Functional Abilities Form for Planning Early and Safe Return to Work".
It is an offence to deliberately make false statements to the Workplace Safety and Insurance Board.
I declare that all of the information provided on pages 1, 2, and 3 is true.
Type your name and upload, or print and sign before returning to WSIB
Signature
Date (dd/mm/yy)
If you are under the age of 16, your parent or guardian, must authorize the release of the functional abilities information.
Date (dd/mm/yy)
Telephone
Signature
Relationship:
(
)
Type your name and upload, or print and sign before returning to WSIB
Personal information about you will be collected throughout your claim under the authority of the Workplace Safety and Insurance Act, 1997. Your personal information
will be used to administer your claim(s) and programs of the Board. Medical and non-medical information is collected from health care providers, vocational agencies,
labour market service providers, employers, witnesses, Canada Revenue Agency (CRA), and others as required. Your Social Insurance Number is used to register claims,
identify workers and to issue income tax statements and is collected under the authority of the Income Tax Act. Information may only be disclosed to the employer,
external medical consultants, external service providers, researchers, third parties for cost recovery purposes and others as authorized by the Workplace Safety and
Insurance Act and the Freedom of Information and Protection of Privacy Act. Your name and telephone number may be disclosed to third parties conducting satisfaction
surveys and focus groups. Incoming and outgoing calls may be recorded for quality assurance purposes. Questions about this collection should be directed to the
decision maker responsible for your file or by calling 1-800-387-0750.
A more detailed PRIVACY STATEMENT for workers may be found at www.wsib.on.ca or by calling toll free at 1-800-387-0750.
0006A3
Page 3 of 3
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6
Worker's Report
of Injury/Disease (Form 6)
Claim Number
Please PRINT in black ink
Last Name
First Name
Social Insurance Number
K. Additional Information
start >
The Workplace Safety & Insurance Act requires you to give a copy of this report
(Worker's Report of Injury/Disease - Form 6) to your employer
0006A4
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