Work Place Injury Intake
Name
Date of Birth
/
Day
/
Month
Year
Date
Claim Number
Date of Accident
/
Month
/
Day
Year
Date
Area (s) of Injury (that have been reported to WSIB)
Have you received any treatment for this injury to date?Type a question
Referring Health Professional (If Applicable)?
Current Job Title/Occupation
Length of Time in Current Job
Current Employment Status
Full Time
Part-Time
Regular Duties
Modified Duties
Regular Hours
Modified Hours
Not Working
If not working – How long do you think you will be off work?
Employer Name
Employer Address
Employer Address
Supervisor/Contact Name
Number
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