1 wsib FORM 6 AND FUNCTIONAL ABILITIES FORM. INSTRUCTIONS FOR COMPLETION. If you are using this 9 (nine) page package, you have sustained a workplace injury in the course of duty that requires medical assessment/treatment. You are required to complete these forms in order to establish a claim with wsib and receive benefits to assist in your recovery. Completing an Employee Incident Report (EIR) does NOT establish a wsib claim for a workplace injury !!! This package contains the following wsib Forms: Form 6 Worker's Report of Injury/Disease (4 pgs). To be completed by you as soon as possible after your injury. FUNCTIONAL ABILITIES Form for Planning Early and Safe Return to Work Form (FAF).
2 (4 pgs). To be completed by your attending Healthcare Professional Once the forms are complete: 1. Fax both (Form 6 AND FAF) to: Disability Management Coordinator: 1-866-604-5311.. CUPE 1019 Office: (905) 680-7946 *. *(Optional only if you would like Union assistance in your claim): 2. Fax the Form 6 to: wsib : 1-888-313-7373. If you require any assistance completing the Form 6, please call or email: Jim Simpson CUPE 1019 wsib and Benefits Advisor Cell: (905) 984-1340 Email: Blaine Bittman CUPE 1019 Secretary and wsib Advisor Cell: (905) 329-4237 Email: Canadian Union of Public Employees, Local 1019, 133 Front St. N., Unit 6, Thorold, ON.
3 L2V 0A3. 6. Worker's Report of Injury/Disease (Form 6). Mail To: OR Fax To: Workplace Safety and 416-344-4684. Insurance Board OR 1-888-313-7373. 200 Front Street West Toronto ON M5V 3J1 Claim Number Ple ase PRINT in black ink print reset save A. Worker Information Last Name First Name Social Insurance Number start >. Address (number, street, apt., suite, unit) Telephone City/Town Province Postal Code Alternate/Cell Phone Job Title/Occupation (at the time you were hurt) Date you dd mm yyHow long have you started been doing this job with employer for this employer? check if you Date of dd mm yy Only executive elected official owner spouse or relative of the employer are one of the following: Birth Sex Your Preferred Language Would an interpreter M F English French Other be helpful?
4 Yes no 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 in this claim? file status information to your union representative? yes no yes no yes no Provide your Union Name and Local CANADIAN UNION OF PUBLIC EMPLOYEES - LOCAL 1019. B. Employer Information Company/Employer Name REGIONAL MUNICIPALITY OF NIAGARA - PUBLIC HEALTH DIVISION - NIAGARA EMS. Address 1815 SIR ISAAC BROCK WAY. City/Town Province Postal Code THOROLD ONT L2V 4T7. Your Immediate Supervisor's Name Company Telephone 905 984-5050. C. Accident/Illness Dates & Details 1. Date and hour dd mm yy AM 2.
5 Who did you report this accident/illness to? (Name & Position). of accident/Awareness PM. of illness Date and hour reported dd mm yy AM Telephone to employer PM. 3. Area of Injury (Body Part) - (Please check all that apply). Head Teeth Upper back Left Right Left Right Left Right Left Right Face Neck Lower back Shoulder Wrist Hip Ankle Eye(s) Chest Abdomen Arm Hand Thigh Foot Ear(s) Pelvis Elbow Finger(s) Knee Toe(s). Forearm Lower Leg Are you: Other: Left Handed Right handed 4. Did the accident/illness happen on yes no Specify where it happened (shop floor, warehouse, client/customer site, parking lot, etc.): the employer's property or work site?
6 5. Did it happen outside the Province yes no If yes, indicate where of Ontario? (city, province/state, country): 6. Have you hurt this area(s) of your yes no 7. Do you have any prior no yes - In Ontario yes - Outside Ontario body before? related wsib /WCB claims? A guide to complete this form is available at 0006A (02/13) Page 1 of 3. next page Worker's Report Please PRINT in black ink 6 of Injury/Disease (Form 6). Claim Number Worker Name - 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 ( 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).
7 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).
8 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. D. Health Care Information Give your Health Professional your wsib Claim number. 1. Did you get first aid yes no If yes, when dd mm yy and by whom (Name): or care at work 2. Where did you go for health care, for your injury, outside of work? (Check all that apply). Facility/Hospital (Name & Address) Date of Visit (dd/mm/yy). Nursing Date of Visit (dd/mm/yy) Ambulance Station Emergency Health Department Professional Office Admitted to Clinic Hospital 3.
9 Were you prescribed any medications/drugs? yes no 4. Were you referred for any other treatment or tests? yes no 5. Did you talk to your health professional about going back to yes no If yes, were you given yes no regular or modified work? any work limitations? 6. Did you tell your employer you went for medical treatment? yes no If no, please tell your employer right away. dd mm yy Name If yes, when? and to whom? Position 0006A2 (02/13) Page 2 of 3. next page Worker's Report Please PRINT in black ink 6 of Injury/Disease (Form 6). Claim Number Worker Name - Last Name First Name Social Insurance Number E. Lost Time & Return to Work 1.
10 After the day of accident/illness: start > I returned to work to my regular job and did not lose any time or pay. I returned to modified duties and did not lose any time or pay. I lost time and/or pay ( 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 Date of your return to work If yes regular work modified work If no Did you discuss return to work with Does your employer have modified work? your employer? yes no yes no 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.