Community Living Oshawa/Clarington (CLOC) HUMAN

Transcription

Community Living Oshawa/Clarington (CLOC)
HUMAN RESOURCES POLICIES & PROCEDURES
RETURN TO WORK/DISABILITY MANAGEMENT
EFFECTIVE DATE:
June 1998
REVISION/REVIEW
November 2010
DATE APPROVED BY BOARD OF DIRECTORS
Signed: Garry Cooke
November 2010
SCOPE:
All employees.
RATIONALE:
To ensure the early and safe rehabilitation of injured/ill employees in a fair, respectful and consistent
manner, having regard to each individual's circumstances.
Early intervention is considered the cornerstone of the Return to Work Program and disability
management.
POLICY STATEMENT:
All CLOC employees are responsible for participating in their rehabilitation through the Return to Work
Program.
Community Living Oshawa/Clarington takes all reasonable steps to return injured and ill employees to
their pre-injury job as quickly as possible. Where the employee is temporarily or permanently unable to
return to their pre-injury job as a result of either an occupational or non-occupational injury or illness,
CLOC makes reasonable effort to provide suitable meaningful employment to employees which is
consistent with their functional abilities.
References:
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Ontario Occupational Health & Safety Act (RSO 1990. C. 0. 1)
Workplace Safety and Insurance Act, 1997
Human Rights Code R.S.O. 1990
Ontario Regulation 67/93 Health Care and Residential Facilities
Collective Agreement between CLOC and the Canadian Union of Public Employees, Local 2936,
Article 25
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RETURN TO WORK/DISABILITY MANAGEMENT - PROCEDURE
GENERAL PROCEDURES
The Return to Work (RTW) program begins immediately upon the report of injury or illness by an
employee to their supervisor. The program applies to all employees with a medical condition, whether
work related or not, who are unable to perform full duties as documented by a health care professional.
The RTW program is a collaborative effort of the injured employee, their supervisor, RTW coordinator,
health care professional, and Workplace Safety and Insurance Board (WSIB) if applicable.
As soon as medical information is received from the injured/ill employee the supervisor prepares the
RTW plan in consultation with the RTW coordinator and the employee. Where medical information is
not available from the health care provider, the WSIB Standard Restrictions will be used to determine
functional abilities. The RTW plan must include:
 Short and long term goals with time frames.
 Accommodations.
 Restrictions and limitations.
 Hours.
 Location.
 Roles and responsibilities of employee and management and any other parties involved in the
plan.
 Give the employee a clear understanding that any problems or difficulties are immediately
brought to the attention of a supervisor or designate.
The ultimate goal of the RTW program is to return the injured/ill employee to their pre-injury job as
soon as it is safe to do so. When this is not possible, other suitable, available and sustainable work is
offered which may include modifications to the pre-injury or other available job, flexible schedule, and
change of location.
When identifying suitable work, consideration will be given to the employee's ability and skills. Every
effort is made to ensure that the work assigned is suited to both the employee's physical and personal
abilities, and contributes to the delivery of services. Definition of Suitable Work:
Is within the employee's functional abilities
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The employee has, or is able to acquire, the necessary skills to perform
Does not pose a health or safety risk to the employee or coworkers, and
If possible, restores the employee's earnings.
Is meaningful and productive
Available at the pre-injury/illness site or at a comparable worksite
The timely implementation of the RTW program enables CLOC:
 To reduce the number of days lost to injury or illness
 To lessen the financial and emotional impact of the injury or illness on the employee
 To reduce the costs related to work and non-work-related injury or illness
 To educate employees on disability management
Page 2 of 7
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To comply with all legislation, including the Workplace Safety and Insurance Act and Human
Rights Code
The modified return to work assignment will end once the injured employee has been declared fit to
resume their pre-injury/illness position.
Where this is not possible, consideration may be given to permanent modification or to providing
alternate employment within Community Living Oshawa/Clarington. This may include training and/or
the modification of workstations or equipment to accommodate injured employees providing that such
accommodation does not create undue hardship to Community Living Oshawa/Clarington.
The completion of a RTW plan can occur in three ways:
 The employee returns to pre-injury or comparable work and pre-injury wages.
 The employee returns to work with the accident employer to permanent suitable work.
 The employee is unable to return to work. If the employee is unable to return to work due to
the nature of the injury, the employee will undergo a Labour Market Re-entry Assessment
(LMRA).
EMPLOYER RESPONSIBILITIES
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Provide a safe work environment.
Promptly report work-related injuries/illnesses to the WSIB when they occur.
Develop written return to work policies and procedures that are fair and consistently applied to all
employees.
Educate all employees about the RTW program.
Train all supervisors in effective return to work strategies and incident investigation.
Train employees on proper reporting of incidents.
Contacting the employee as soon as possible after the injury occurs and maintaining communication
throughout the period of the employee's recovery and impairment.
Work with the employee and the treating health professional to identify suitable work.
Attempt to provide suitable employment that is available and consistent with the employee's
functional abilities and that, when possible, restores the employee's pre-injury earnings.
Modify the workplace where possible, to accommodate employees who are disabled due to illness
or injury.
Monitor the progress of employees in modified work programs and meet with them regularly to
ensure they are successful in achieving their return to work goal.
Communicate with the WSIB such information as the WSIB may request concerning the employee's
return to work.
Operate in compliance with the Workplace Safety and Insurance Act, Section 40(1) and any other
relevant legislation.
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SUPERVISOR RESPONSIBILITIES
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Take appropriate action when an injury or illness is reported.
Immediately following the report of injury or illness that will result in lost time, the supervisor is
required to make early and considerate contact (within 24 hours) with the injured/ill employee to
discuss the following:
 The type, extent, cause and circumstances of the injury or illness.
 Transportation to get medical care, if needed.
 Requirements for reporting work-related injuries and illnesses.
 Ensure that the employee is aware of the Return to Work policy and location and requirements
of all documentation.
 Any foreseen obstacles to RTW.
Maintain contact with the injured/ill employee as often as daily in the first week and at least weekly
thereafter.
Participate in return to work planning.
Identify appropriate work duties, transitional work options and temporary or permanent job
accommodations for employees with disabilities.
Monitor safe work practices of employees who are returning to work.
Answer co-workers’ questions and concerns about employees with disabilities, job modifications,
job restructuring, etc., while maintaining the confidentiality of the employee’s situation.
Complete all required documentation for the Return to Work plan.
Promote safe work practices and support the efforts of the company’s health and safety program.
Operate in compliance with the Workplace Safety and Insurance Act, Section 40 and any other
HEALTH & SAFETY MANAGER (RTW Coordinator) RESPONSIBILITIES
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To coordinate all parties to effectively carry out the RTW process.
Maintain scheduled communication with the injured/ill employee, supervisor and the WSIB.
Offer assistance to the injured/ill employee and their supervisor with regards to all aspects of the
RTW process.
Ensure the timely and complete reporting of all documents to the WSIB.
Monitor and evaluate the employee's recovery and progress through the RTW process.
Prepare and distribute statistical reports to senior management and to the Joint Health and Safety
Committee.
Prepare an evaluation of the RTW process and performance annually.
Operate in compliance with the Workplace Safety and Insurance Act, Section 40 and any other
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INJURED/ILL EMPLOYEE RESPONSIBILITIES
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Understand and follow safety policies and procedures.
Report any injury/illness immediately to a supervisor or designate and seek medical attention as
soon as possible and as necessary.
Report to a supervisor or designate with the completed Form 6 and Functional Abilities Form as
soon as is practical. If unable to report to work because of the extent of the injuries, contact a
supervisor or designate immediately.
Obtain a Return to Work Package before seeing the medical healthcare professional if you believe
the injury/illness to be work-related.
If medical attention is necessary, inform the treating medical healthcare professional that return to
work opportunities are available in the workplace to accommodate their physical abilities. Keep the
treating health professional informed about return to work options and injury/illness symptoms.
Maintain communication throughout the period of the impairment and recovery.
Inform a supervisor or designate about any concerns with treatment, benefits, work duties, changes
in circumstances, etc.
Assist the employer to identify suitable employment that is available and consistent with the
employee's functional abilities and that, where possible, restores his or her pre-injury earnings.
Take an active role in developing their return to work plan.
Obtain the necessary documentation from the treating health professional as may be required by
the employer (for example, functional abilities information)
Report any changes in their condition or concerns with the return to work to a supervisor or
designate.
Attend scheduled RTW progress meetings with the employer.
Timely completion of all required documents.
Operate in compliance with the Workplace Safety and Insurance Act, Section 40(2) and any other
Failure of the employee to co-operate and take an active role in return to work may have their
benefits suspended or reduced by the WSIB.
OTHER STAKEHOLDER RESPONSIBILITIES
The Joint Health and Safety Committee offers recommendations for the development, establishment
and implementation of the RTW procedures. The committee will also review relevant documents and
statistical reports.
CLOC and CUPE 2936 (02 and 03), the Union representing the employees of CLOC, agree to work
collaboratively to ensure the return to meaningful employment of all injured/ill employees.
Co-workers of the injured/ill employee are required to cooperate in any RTW process.
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RETURN TO WORK COMMITTEE RESPONSIBILITIES
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In complex cases when employees may need to be accommodated outside of their classification or if
representation is requested by the employee, the parties agree to establish a Return to Work
Committee.
A meeting is arranged with the employee, Union Representative, supervisor and Human Resources
to establish the return to work process.
Compare the functional abilities with the physical requirements of pre-accident job.
Modify the pre-accident job to the functional abilities (if possible/necessary) utilizing the Job
Demand Analysis for the employee’s location.
If the pre-accident job cannot be modified to suit the employee’s functional abilities, then the
committee will attempt to find other suitable work within the employee's functional abilities. The
suitable work must be safe, available and sustainable.
The committee jointly develops and agrees on the Return to Work Plan.
Any dispute will be dealt with using the complaint resolution procedures outlined in the CLOC
Communication policy
HEALTH CARE PROVIDER ROLE (educational note)
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Provide appropriate, effective health care that facilitates recovery and expedites return to
productive work.
Provide information on the employee’s functional abilities when requested by the company, the
employee or the WSIB.
Complete functional assessment forms thoroughly, being alert to job demands that might cause reinjury or aggravation of an existing condition.
Suggest ways in which tasks could be modified to place less strain on existing injuries or conditions.
Establish and maintain open communication with the employer, having regard for patient
confidentiality.
Provide timely information to the WSIB.
WSIB ROLE (educational note)
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Provide education to employees and employers.
Actively manage and monitor activities, progress and co-operation of the workplace parties.
Maintain communication with the employer, the employee and their treating health professional
throughout the RTW process.
Determine the suitability of employment and fitness to return to work.
Encourage and actively assist the employee in their successful RTW.
Determine compliance with re-employment and co-operation obligations.
Provide RTW resources that the workplace parties may choose to access.
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RETURN TO WORK/DISABILITY MANAGEMENT – PROCEDURE
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Provide Labour Market Re-entry services.
In cases where the workplace parties are having trouble achieving a successful RTW outcome,
 Assist workplaces to problem solve workplace issues that present an obstacle to successful RTW.
 Facilitate communication between workplace parties, health professionals, unions and other
stakeholders.
 Obtain commitment from the employee and employer on the RTW plan and process.
 Attempt to resolve disputes that are preventing a successful RTW outcome.
TRAINING
Initial training begins with a review, discussion and sign off of this policy and procedure during new
employee orientation. This process is reviewed with all employees on an annual basis during Health &
Safety Awareness training. This policy and procedure will be further reviewed with the Annual Review
and Sign Off of Policies (CLOC Policy Development, Review & Implementation).
EVALUATION
An evaluation of our RTW program will be completed annually by the Health and Safety Manager and
presented to senior management. The purpose of the evaluation is to determine the level at which we
are meeting the objectives of the program.
Each employee and supervisor who has been through the RTW process will independently complete an
evaluation at the end of the return to work.
CLOC is committed to using the results of our evaluations to improve our program.
Signed: Steven Finlay, Executive Director
July 12, 2010
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FORMS & DISTRIBUTION
Form
WSIB Form 6
WSIB Form 7
WSIB Functional Abilities Form
(FAF)
CLOC Physical Capabilities
Form (PCF)
CLOC Cognitive Functional
Abilities
CLOC Accident Investigation
Commitment Letter to
Physician
Letter to Employee (offer
RTW)
RTW Accommodation Plan
Employee Weekly Report
Supervisor Weekly Report
Employee Post RTW
Evaluation
Supervisor Post RTW
Evaluation
Claims Management Checklist
Contact Log
Timeline
Prepared by
Distributed to
Immediately following workplace
injury/illness
Immediately following report of workplace
injury/illness and subsequent investigation
Completed at first medical visit and forwarded
immediately following
immediately following (non work related)
immediately following (non work related)
Immediately following report of workplace
injury/illness
Sent with FAF to Health Care Professional
Employee
Supervisor, RTW Coordinator, WSIB
Supervisor
RTW Coordinator, WSIB, Employee
Treating Health Care Professional
Supervisor
Employee, Supervisor, RTW
Coordinator, WSIB
Coordinator, WSIB
Coordinator, WSIB
RTW Coordinator
RTW Coordinator
Prepared as soon as suitable employment is
arranged
Prepared as soon as possible after the offer is
made and before work commences
Prepared daily and submitted weekly until the
RTW plan is closed
Weekly until the RTW plan is closed
Within one week of the close of the RTW plan
RTW Coordinator
Employee, Supervisor, WSIB
Coordinator (committee if necessary)
Coordinator, WSIB
Supervisor, RTW Coordinator
Employee
RTW Coordinator
Within one week of the close of the RTW plan
Supervisor
RTW Coordinator
As required throughout the length of the
claim
As required throughout the length of the
claim
RTW Coordinator
Claim File
Claim File
*Other forms or letters may be required and prepared on a case by case basis.
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Claims Management Procedure Checklist
Accident Date:
Worker’s Name:
Manager:
ID Number:
Location:
Type of Injury:
Violence involved Y/N:
Accident/Illness Report Received?
Yes  No 
Date: _______________
Form 6 received from Worker?
Yes  No 
Date: _______________
Form 7 received from Manager?
Yes  No 
Date: _______________
Form 7 submitted to WSIB?
Yes  No 
Date: _______________
Copy of Form 7 sent to Worker?
Yes  No 
Date: _______________
Memo to Worker for WSIB reimbursement?
Yes  No 
Date: _______________
Copy of Form 7 sent to JHSC?
Yes  No 
Date: _______________
Functional Abilities Form Received?
Yes  No 
Date: _______________
Claim Established by WSIB?
Yes  No 
Date: _______________
Claim # _____________________________
Claim Accepted or Denied?
Accepted 
Claim Type:
Denied 
First Aid 
Health Care 
Lost Time 
Modified Duties over 7 days 
Claim under Appeal?
Yes  No 
Date: ______________
Additional Functional Abilities Form required/received? Yes  No 
Date: ______________
Return to Work Plan developed?
Yes  No 
Date: ______________
Return to Work Plan discussed with Worker?
Yes  No 
Date: ______________
Modified Job Offer presented to Worker?
Yes  No 
Date: ______________
Modified Job Offer accepted or declined
Return to Work Date:
Status: _____________________________
Date: _____________________________
Form 9 submitted to WSIB?
Yes  No 
Long Term Earnings information submitted to WSIB?
Yes  No 
Date: ______________
Date: ______________
Comments/Notes/Follow-up: _______________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
May 2012
1
Cognitive Functional Abilities for Safe and Early Return to Work
Worker’s Name: _____________________________
Date of Birth :_____________(M/D/Y)
In consideration of the worker’s medical condition;
1. Is the worker able to perform duties in any capacity at this time? Yes: ___ No: ___
IF NO: Indicate appointment for reassessment ______________
IF YES: Is the worker able to return to full duties immediately? Yes: ___ No: ___ (if no please complete the
following questions;
1. Functional/cognitive/psychological capabilities: Able to;
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exercise full cognitive abilities
maintain concentration/ attention span
exercise full memory capabilities
exercise sound judgment
maintain stamina
handle tight deadlines
handle shifting priorities
handle multiple simultaneous demands
work and problem solve with accuracy
work and problem solve with speed
work independently
receive and act upon written and verbal instructions
Yes:___ No:___
Yes:___ No:___
Yes:___ No:___
Yes:___ No:___
Yes:___ No:___
Yes:___ No:___
Yes:___ No:___
Yes:___ No:___
Yes:___ No:___
Yes:___ No:___
Yes:___ No:___
Yes:___ No:___
Specific limitations/ general comments: _________________________________________________________
__________________________________________________________________________________________
2. Limitations for Work Hours/ Shift Work
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Full hours Yes:___ No:___ If “No” please complete the following;
Shift Work Yes:___ No:___ If “No” please complete the following:
Proposed Return to Work Schedule
Week #
Number of days/week
1
2
Number of hours/shift (4, 8, 12)
Shifts (day, evening, night)
Other/ general comments/ specific limitations ______________________________________________
___________________________________________________________________________________
Date of assessment on which the above information is based: ______________
Date of next assessment:
_____________________________
Physician’s printed name: _____________________________
Physician’s signature: ________________________________
Date: _______________________
01/24/08
May 2012
EMPLOYEE POST RTW EVALUATION
Name:
Claim #:
Date of Accident:
Supervisor:
1.
Was your injury/illness work related?
yes 
2.
What was the length of time following your injury/illness prior to beginning the RTW plan? ________________
3.
What was the duration of your RTW plan? _______________
4.
Did you understand your responsibilities in the RTW plan as listed:
a)
Reporting your injury/illness?
yes 
b)
Seeking medical attention?
yes 
c)
Assisting with the completion of forms?
yes 
d)
Cooperating with the RTW plan?
yes 
e)
Attending RTW meetings?
yes 
f)
Maintaining contact with your supervisor? yes 
g)
Reporting changes of medical condition?
yes 
5.
Do you feel that you were treated with compassion and respect during your recovery and RTW period by:
a)
Your supervisor?
yes 
no 
b)
Human Resources?
yes 
no 
c)
Your co workers?
yes 
no 
6.
Do you consider early intervention and return to work in the Modified Work Program assisted you with your recovery?
yes 
no 
7.
Did you receive adequate information regarding the program prior to returning to work?
yes 
no 
8.
Did you receive adequate support from:
a)
Supervisor
b)
Co-workers
c)
Human Resources
d)
Physician
9.
Do you feel that the assigned tasks allowed you to be a productive and contributing member of the team?
yes 
no 
yes 
yes 
yes 
yes 
no 
no 
no 
no 
no 
no 
no 
no 
no 
no 
no 
no 
10. Did you receive Occupational Therapy or Physiotherapy assistance, or alternate therapy?
yes 
no 
If no, indicate what therapy you received:
_________________________________________________________________________________________
11. Did you feel the services adequately met your needs?
yes 
12. Was there a sufficient amount of supervision from your supervisor?
yes 
May 2012
Page 1 of 2
no 
no 
13. Was there sufficient contact (daily, weekly, as needed) with your supervisor and Human Resources?
yes 
no 
14. RTW policy:
Is there a written RTW policy for your workplace?
If yes, have you seen a copy of the policy?
Are there written procedures for RTW?
If yes, are they easy to understand and follow?
Have you ever seen a copy of the procedures?
Have you received education prior to injury/illness?
If yes, was the education adequate?
yes 
yes 
yes 
yes 
yes 
yes 
yes 
no 
no 
no 
no 
no 
no 
no 
15. Please explain rationale for all negative responses, identify possible recommendations/input to change for future
return to work plans:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
16. Additional comments or concerns:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Employee Signature: ___________________________________ Date: _________________________
May 2012
Page 2 of 2
EMPLOYEE RTW WEEKLY REPORT
Name:
Claim #:
Date of Accident:
Date of Medical Info(FAF):
Week # of Plan:
Supervisor:
Date
1.
Scheduled
Hours
Hours
Worked
Tasks Performed
Did you have any discomfort in the affected area and/or emotional concerns before you commenced work today?
yes ___
no ___
If yes, please describe the amount of discomfort, on what movements, type of discomfort and if this is unusual and/or
the nature of your emotional concerns:
_________________________________________________________________________________________
_________________________________________________________________________________________
2.
While performing the tasks assigned to you, did you experience an increase, or decrease in discomfort and/or
emotional concern?
yes ___
no ___
If this difference was significant, please describe:
_________________________________________________________________________________________
_________________________________________________________________________________________
3.
Were you able to complete all of your assigned tasks?
yes ___
no ___
If no, please comment:
_________________________________________________________________________________________
May 2012
Page 1 of 2
_________________________________________________________________________________________
4.
Do you feel you are able to add tasks?
If yes, what types of tasks:
_________________________________________________________________________________________
_________________________________________________________________________________________
5.
List any tasks that you had difficulty with and explain what difficulty:
_________________________________________________________________________________________
_________________________________________________________________________________________
6.
Do you feel that the duties assigned to you were productive and allowed you to contribute to the team?
yes ___
no___
If no, please comment:
_________________________________________________________________________________________
_________________________________________________________________________________________
7.
Comments or concerns:
_________________________________________________________________________________________
_________________________________________________________________________________________
Employee Signature: ___________________________________ Date: _________________________
Supervisor Signature: __________________________________
May 2012
Page 2 of 2
Date: _________________________
Inspiring Possibilities
Date
Employee
Address
Claim #
RE: OFFER OF SUITABLE WORK
Dear employee:
We are sorry to hear of the injury and hope that your recovery will be swift and complete.
It is Community Living Oshawa/Clarington’s policy to make reasonable efforts to provide suitable
employment to an employee who is unable to perform his/her regular duties as a result of a job-related
injury or illness.
This letter is to confirm our discussion on date regarding your plan for return to work. As we agreed,
your tasks will be assigned consistent with your functional abilities, skills and knowledge. These duties
are available immediately, provided your medical precautions allow you to return to work. In the
absence of the standard FAF your job modifications will be made in accordance with WSIB’s standard
restrictions.
Under the Workplace Safety and Insurance Act, it is your obligation as an injured employee to maintain
regular contact with your employer and assist in arranging an early and safe return to work. We have
enclosed a copy of your regular job description and will discuss how these duties may be modified at the
initial return to work meeting. We appreciate any input that will assist in identifying suitable
employment.
I am requesting that you contact me by date in order that we can schedule a time to meet.
Communication thereafter must be at minimum, on a weekly basis, to provide an update on your
condition and your availability to return to work.
If you have any questions, please contact me at (905) 576-3011.
Sincerely,
Supporting people who have an intellectual disability.
39 Wellington Avenue East
Oshawa, Ontario L1H 3Y1
t. 905-576-3011
f. 905-576-9754
Charitable Registration Number: 108091307RR0001
info@communitylivingoc.ca
www.communitylivingoc.ca
May 2012
A. Section A to be completed by the employer and/or worker.
First Name
PCF
Physical Capabilities Form
for Early/Safe Return to Work
Worker's Last Name
Telephone
City/Town
Address (no., street, apt.)
Province
Employer's Name
Date of Birth
(dd/mm/yyyy)
Community Living Oshawa Clarington
Full Address (No., Street, Apt.)
Date of Awareness
of Illness/Injury
(dd/mm/yyyy)
City/Town
Prov.
Oshawa
Postal Code
Ont.
Postal Code
Employer
Telephone
L1H 3Y1
1. Type of job at time of Ilness/Injury (if available, please attach description of job activities)
Area(s) of injury(ies)/illness(es)
2. Have the worker and the employer discussed Return To Work
lf no, will be discussed on
yes
no
3. Employer contact name
dd
fold
fold
Employer
Fax No.
mm
yyyy
Position
B. Worker's Signature
By signing below, I am authorizing any health professional who treats me to provide me and my employer with
information about my functional abilities on the Community Living Oshawa Clarington's "Physical Capabilities for Planning Early and Safe Return to Work" form.
Signature
Date
dd
mm
yyyy
mm
yyyy
C. Health Professional's Information
Health Professional's Designation
Chiropractor
Physician
Physiotherapist
Registered Nurse (Extended Class)
Other
Health Professional's Name (please print)
Address (No. Street, Apt.)
Province
City/Town
Postal Code
Fax
I hereby declare that the information being submitted in Sections C, D, E and F of this form is true and complete.
Health Professional's Signature
May 2012
Telephone
Date
dd
Page 1 of 2
PCF
First Name
Worker's Last Name
Physical Capabilities Form
for Early/Safe Return to Work
D. The following information should be completed by the Health
Professional to identify the patient's overall abilities and restrictions.
1. Date of
Assessment
dd
mm
yyyy
2. Please check one:
Patient is capable of
returning to work with
Patient is capable of returning
to work with restrictions .
Complete sections E and F.
no restrictions.
Patient is physically unable to
return to work at this time.
Complete section F.
E. Abilities and/or Restrictions
1. Please indicate Abilities that apply. Include additional details in section 3
Walking:
Standing:
Full abilities
Up to 100 metres
100 - 200 metres
Other (please specify)
Lifting from waist to shoulder:
Full abilities
Up to 5 kilograms
5 - 10 kilograms
Sitting:
Lifting from floor to waist:
Full abilities
Up to 15 minutes
15 - 30 minutes
Full abilities
Up to 30 minutes
30 minutes - 1 hour
Stair climbing:
Full abilities
Up to 5 steps
5 - 10 steps
Ladder climbing:
Full abilities
1 - 3 steps
4 - 6 steps
Full abilities
Up to 5 kilograms
5 - 10 kilograms
Travel to work:
Ability to use
public transit
Ability to
drive a car
yes
no
yes
no
2. Please indicate Restrictions that apply. Include additional details in section 3
Bending/twisting
repetitive movement of
(please specify)
Limited pushing/pulling with:
Left arm
Right arm
Work at or above
shoulder activity:
Limited use of hand(s):
Environmental
exposure to: (e.g. heat,
cold, noise or scents)
Chemical
exposure to:
Operating motorized equipment:
(e.g. forklift)
Left
Right
Gripping
Pinching
Potential side effects from
medications (please specify)
Do not include names of
medications.
Exposure to vibration:
Whole body
Hand/Arm
3. Additional Comments on Abilities and/or Restrictions.
4. From the date of this assessment, the above will apply for approximately:
1 - 2 days
3 - 7 days
6. Recommendations for
work hours and start date:
8 - 14 days
5. Have you discussed return to work
with your patient?
14 + days
Regular full-time hours
Modified hours
Graduated hours
yes
Start Date
dd
no
mm
yyyy
F. Date of Next Appointment
Recommended date of next appointment to review Abilities and/or Restrictions.
I have provided this completed Physical Capabilities Form to:
May 2012
dd
Worker
mm
yyyy
and/or
Employer
page 2 of 2
May 2012
RETURN TO WORK ACCOMODATION PLAN
Name:
Claim #:
Pre Injury Location:
Pre Injury Job Title:
Supervisor:
Injury:
Plan Start Date:
Date of Accident:
Target Completion Date:
Short Term Goal:
Long Term Goal:
Physical Restrictions/Limitations/Precautions:
• Lifting –
• Bending and twisting –
• Use of ladder –
• Use of stairs –
• Use of vehicle –
WORK PLAN DETAILS
Location:
Supervisor:
Weekly Hours of Work:
Next Medical Reassessment:
Job Title:
Duration of Plan:
Next Plan Review:
Tasks that are NOT to be performed:
•
Duties and Obligations:
• Abide by the restrictions as outlined.
• Contact available co-workers on shift to assist where necessary.
• Keep your supervisor updated of your progress or changes to medical condition.
• Immediately contact your supervisor with any concerns that arise as a result of the modified duties.
GRADUATION OF HOURS EACH WORK DAY
Date
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Week 1
Week 2
Week 3
Week 4
We agree to the modified position listed above and will maintain the restrictions listed for the duration of the work plan.
Employee Signature: ___________________________________
Date: _________________________
Print Name: _______________________________
Print Name: _______________________________
Date: _________________________
Inspiring Possibilities
Return to Work Commitment Statement
Dear Health Care Professional,
RE: WSIB Functional Abilities Form
Community Living Oshawa Clarington (CLOC) is committed to providing early and safe return to work
programs for ill or injured employees. Modified duties and/or hours are designed on an individual basis
depending on identified functional abilities. The goal of the program is to return the employee to safe
and meaningful work leading to sustained and relapse-free employment.
The injured/ill employee’s supervisor will review your completed functional ability evaluation form and
develop a program consisting of duties within our employee’s limitations and/or restrictions. Ideally all
programs shall be no longer than 4-16 weeks in duration.
In order to facilitate an early and safe return to work, please complete the enclosed WSIB functional
abilities form for immediate return to CLOC. A job description and/or a job demands analysis will be
provided upon request. Should you require additional information please contact
___________________ at ___________________.
Health and Safety Manager
905 576 3011 x343
905 576 9754 fax
Supporting people who have an intellectual disability.
Oshawa, Ontario L1H 3Y1
t. 905-576-3011
f. 905-576-9754
Charitable Registration Number: 108091307RR0001
info@communitylivingoc.ca
www.communitylivingoc.ca
May 2012
RETURN TO WORK CONTACT LOG
Date of Accident:
Claim #:
Name:
Phone #:
Supervisor:
Phone #:
Treating Physician:
Phone #:
WSIB Case Manager:
Phone #:
Date of
Contact
May 2012
Person Contacted
Details of Conversation
1
SUPERVISOR POST RTW EVALUATION
Name:
Claim #:
Date of Accident:
Supervisor:
1.
What was the length of time following the injury/illness prior to beginning the RTW plan? ________________
2.
What was the duration of the RTW plan? _______________
3.
Did you understand your responsibilities in the RTW plan as listed:
a)
Assisting with the completion of forms?
yes 
b)
Cooperating with the RTW plan?
yes 
c)
Attending RTW meetings?
yes 
d)
Maintaining contact with your employee? yes 
4.
Do you consider early intervention and return to work in the Modified Work Program assisted the employee with
his/her your recovery?
yes 
no 
5.
Do you feel that the employee received adequate information regarding the program prior to returning to work?
yes 
no 
6.
Do you fell the employee received adequate support from:
a)
Supervisor
yes 
b)
Co-workers
yes 
c)
Human Resources
yes 
d)
Physician
yes 
7.
Do you feel that the assigned tasks allowed the employee to be a productive and contributing member of the team?
yes 
no 
8.
Did the employee receive Occupational Therapy or Physiotherapy assistance, or alternate therapy?
yes 
no 
9.
Did you feel the services adequately met the employee’s needs?
yes 
no 
no 
no 
no 
no 
no 
no 
no 
no 
10. Were there any difficulties faced in modifying the work to accommodate employee?
yes 
no 
If so, describe? (ie. coverage, communication with Human Resources, physician, WSIB or employee):
______________________________________________________________________________________
______________________________________________________________________________________
11. Do you feel you had the necessary resources to provide a sufficient amount of supervision to the employee?
yes 
no 
12. Was there sufficient contact (daily, weekly, as needed) between you, Human Resources and the employee?
yes 
no 
May 2012
Page 1 of 2
13. Please explain rationale for all negative responses, identify possible recommendations/input to change for future
return to work plans:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
14. Additional comments or concerns:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Supervisor Signature: ___________________________________ Date: _________________________
May 2012
Page 2 of 2
May 2012
SUPERVISOR RTW WEEKLY REPORT
Name:
Claim #:
Date of Accident:
Week # of Plan:
Supervisor:
1.
Were all of the assigned hours worked?
yes ___ no ___
If not, why?
_________________________________________________________________________________________
_________________________________________________________________________________________
2.
Were all of the assigned tasks completed?
yes ___
no ___
If not, why?
_________________________________________________________________________________________
_________________________________________________________________________________________
3.
Do you feel that more tasks could be added?
If so, which ones?
_________________________________________________________________________________________
_________________________________________________________________________________________
4.
Do you feel that assigned tasks allowed the worker to be a productive and contributing member of the team?
yes ___
no___ If no, please comment:
_________________________________________________________________________________________
_________________________________________________________________________________________
5.
Did the employee display motivation and a positive attitude while working?
_________________________________________________________________________________________
_________________________________________________________________________________________
6.
Were there any comments or concerns from the employee’s co-workers?
_________________________________________________________________________________________
_________________________________________________________________________________________
7.
Comments or concerns:
_________________________________________________________________________________________
_________________________________________________________________________________________
Date: _________________________
Functional Abilities Form
for Planning Early and Safe Return to Work
Health Professionals, please use this form ONLY when requested by an employer or worker.
The purpose of this form is to identify your patient's overall functional abilities and work
restrictions that will assist his/her return to suitable work.
Please promptly complete and return pages 2 and 3 of this form to the worker or employer
to assist the workplace parties in planning an early and safe return to work.
PLEASE ENSURE YOUR BILLING INFORMATION IS NOT GIVEN TO THE WORKER OR EMPLOYER.
Authority to Release Information
Section 37(3) of the Workplace Safety and Insurance Act, 1997 provides the legal authority for health professionals
to give the Workplace Safety and Insurance Board (WSIB), the injured worker and the employer such information as
may be prescribed concerning the worker's functional abilities.
When completing this report, please print in black ink.
Worker and/or employer should complete Sections A and B of this report. If your patient needs assistance,
please help. Please submit this report even if Section A is not fully completed.
Information about your responsibilities can be found on Page 4.
The WSIB will pay health professionals for completing this form.
Mail to:
Workplace Safety and Insurance Board
200 Front Street West
Toronto, ON M5V 3J1
OR
Fax to:
416-344-4684
or 1-888-313-7373
...go to form
A guide to completing this form is available at
2647A (07/06)
print
Mail to:
Toronto ON M5V 3J1
or Fax to:
416 344-4684
OR 1-888-313-7373
reset
print
Please PRINT in black ink
A. Section A to be completed by the employer and/or worker.
First Name
Worker's Last Name
FAF
Employer's Name
Full Address (No., Street, Apt.)
Prov.
On
Postal Code
Date of Birth
(dd/mm/yyyy)
Date of Accident/
Awareness of Illness
(dd/mm/yyyy)
39 Wellington Ave. E.
City/Town
start >
Province
Oshawa
for Planning Early
and Safe Return to Work
Claim No.
Telephone
City/Town
Address (no., street, apt.)
Postal Code
Employer
Telephone
L1H 3Y1
1. Type of job at time of accident (where available, please attach description of job activities)
Area(s) of injury(ies)/illness(es)
2. Have the worker and the employer discussed Return To Work
lf no, will be discussed on
yes
no
3. Employer contact name
dd
fold
fold
Employer
Fax No.
mm
yyyy
Position
B. Worker's Signature
By signing below, I am authorizing any health professional who treats me to provide me, my employer and the Workplace Safety and Insurance Board (WSIB) with
information about my functional abilities on the WSIB's "Functional Abilities for Planning Early and Safe Return to Work" form.
Signature
Date
dd
mm
yyyy
Please print form & sign before returning to the WSIB
C. Health Professional's Billing Information
For billing purposes fax or mail pages 2 and 3 to the WSIB.
Health Professional's Designation
Chiropractor
Physician
Physiotherapist
Registered Nurse (Extended Class)
Other
PROVIDER BILLING INFORMATION IN THE BOLDED AREA OF SECTION C SHOULD NOT BE PROVIDED TO THE WORKER OR EMPLOYER.
Are you registered
with the WSIB?
yes Please enter the WSIB Provider ID. in the box provided
WSIB Provider ID.
no Please call 1 - 800-569-7919 to register
Health Professional's Name (please print)
Your Invoice Number
Address (No. Street, Apt.)
Service Code
FAF
City/Town
Province
Postal Code
Fax
I hereby declare that the information being submitted in Sections C, D, E and F of this form is true and complete. It is an
offense to knowingly make a false or misleading statement or representation to the WSIB.
Health Professional's Signature
Telephone
Date
dd
mm
yyyy
2647A2 (07/06)
...go to next page
page 2 of 4
Mail to:
Toronto ON M5V 3J1
FAF
or Fax to:
416 344-4684
OR 1-888-313-7373
First Name
Worker's Last Name
for Planning Early
and Safe Return to Work
Claim No.
D. The following information should be completed by the Health
Professional to identify the patient's overall abilities and restrictions.
1. Date of
Assessment
dd
mm
yyyy
2. Please check one:
Patient is capable of
returning to work with
Patient is capable of returning
to work with restrictions .
Complete sections E and F.
no restrictions.
start >
Patient is physically unable to
return to work at this time.
Complete section F.
E. Abilities and/or Restrictions
1. Please indicate Abilities that apply. Include additional details in section 3
Walking:
Standing:
Full abilities
Up to 100 metres
100 - 200 metres
Lifting from waist to shoulder:
Full abilities
Up to 5 kilograms
5 - 10 kilograms
Sitting:
Lifting from floor to waist:
Full abilities
Up to 15 minutes
15 - 30 minutes
Full abilities
Up to 30 minutes
30 minutes - 1 hour
Stair climbing:
Full abilities
Up to 5 steps
5 - 10 steps
Ladder climbing:
Full abilities
1 - 3 steps
4 - 6 steps
Full abilities
Up to 5 kilograms
5 - 10 kilograms
Travel to work:
Ability to use
public transit
Ability to
drive a car
yes
no
yes
no
2. Please indicate Restrictions that apply. Include additional details in section 3
Work at or above
shoulder activity:
Bending/twisting
repetitive movement of
(please specify)
Limited pushing/pulling with:
Left arm
Right arm
Limited use of hand(s):
Environmental
exposure to: (e.g. heat,
cold, noise or scents)
Chemical
exposure to:
Operating motorized equipment:
(e.g. forklift)
Left
Right
Gripping
Pinching
Potential side effects from
medications (please specify)
Do not include names of
medications.
Exposure to vibration:
Whole body
Hand/Arm
3. Additional Comments on Abilities and/or Restrictions.
4. From the date of this assessment, the above will apply for approximately:
1 - 2 days
3 - 7 days
6. Recommendations for
work hours and start date:
8 - 14 days
5. Have you discussed return to work
with your patient?
14 + days
Regular full-time hours
Modified hours
Graduated hours
yes
Start Date
dd
no
mm
yyyy
F. Date of Next Appointment
Recommended date of next appointment to review Abilities and/or Restrictions.
I have provided this completed Functional Abilities Form to:
2647A3 (07/06)
print
reset
dd
Worker
mm
yyyy
and/or
Employer
...go to next page
page 3 of 4
Important Information
To receive benefits, the worker must apply for benefits within six months of the date of a work-related injury or illness.
When filing a claim for benefits, the worker must also consent to the disclosure of functional abilities information
provided by a health professional to his or her employer for the purpose of facilitating an early and safe return to work.
Failure to file a claim or provide consent for the release of the functional abilities information can result in no benefits.
If you have questions about the completion of this form please call 1-800-387-0750.
Worker's Responsibilities
•
•
This form is to be completed by a treating health professional, who will discuss the information with you.
Once completed, contact your employer immediately to review the information on the completed form. Together, you
and your employer will begin to plan an early and safe return to work.
Employer's Responsibilities
• This form provides general information about this worker's functional abilities and restrictions to help you plan an
early and safe return to work.
• When you provide this form to the treating health professional, ensure that you have the worker's signed consent
(Section B) for the release of functional abilities information.
• Where available, also attach a description of the worker's job activities to assist the health professional in completing
the form.
• The prescribed form that is available from the WSIB is a generic form developed to assist with general functional abilities
information.
• The WSIB will pay the health professional to complete the prescribed WSIB form only. A charge will appear on your
Accident Cost statement or Schedule 2 Invoice which reflects the cost of payment for each form completed.
• If you have a form that is specific to your workplace and have the cooperation of the worker in providing consent for the
release of information on your form, you may use your own form. If you create your own form, you must reimburse the
health professional directly.
• Do not send a copy of the completed Functional Abilities Form for Planning Early and Safe Return to Work to the WSIB.
The health professional is responsible for submission of the form.
Health Professional's Responsibilities
• The employer and worker will use this information to plan the worker's early and safe return to work.
• Their return to work plans will reflect the functional abilities and restrictions you have noted and presume that no clinical
contraindications exist for other work activities, therefore it is crucial that all sections be completed in full.
• The completion of this form is based on your examination of the worker and does not require a specialized functional
abilities evaluation.
• Diagnostic or confidential information must not be included.
• Please add specific information on the duration of temporary restrictions or maximum times or weights to be considered,
in section E3 under abilities and/or restrictions . If necessary, attach an additional page to this completed form to
describe abilities and restrictions.
• Completion of this form does not replace clinical reporting requirements to the WSIB .
• Once you have received this form, promptly complete it and give it to the worker and/or employer.
• For billing purposes fax or mail pages 2 and 3 to the WSIB. When faxing, do not mail a copy.
The WSIB will pay the health professional for the completed form when pages 2 and 3 are received.
WSIB Fax 416-344-4684
or 1-888-313-7373
...go to home page
2647A4 (07/06)
A guide to completing this form is available at
page 4 of 4
print
revised march 08 PDF
Workplace Safety and Insurance Board
Toronto ON M5V 3J1
reset
Print
print
Mail To:
Toronto ON M5V 3J1
OR Fax To:
416-344-4684
reset
OR 1-888-313-7373
Reset
Reset
reset this
6
Reset This
Page
page
Claim Number
Social Insurance Number
First Name
Last Name
Address (number, street, apt., suite, unit)
City/Town
Province
Only check if you
are one of the following:
Sex
F
executive
elected official
Your Preferred Language
English
French
Are you a member of a union?
yes
no
Postal Code
Date you
started
with employer
Job Title/Occupation (at the time you were hurt)
M
of Injury/Disease (Form 6)
Reset This
Page
reset this
page
A. Worker Information
Worker's Report
owner
dd
mm
yy
spouse or relative of the employer
Telephone
(
)
Alternate/Cell Phone
(
)
How long have you
been doing this job
for this employer?
dd
mm
Date of
Birth
Would an interpreter
be helpful?
Other
If yes, do you consent to the disclosure of verbal claim
file status information to your union representative?
Do you authorize your union to represent you
in this claim?
yes
no
yy
yes
no
yes
no
Provide your Union Name and Local
B. Employer Information
Company/Employer Name
Address
City/Town
Province
Oshawa
Ont
Postal Code
L1H 3Y1
Company Telephone
( 905 ) 576-3011
Your Immediate Supervisor's Name
C. Accident/Illness Dates & Details
dd
mm
yy
1. Date and hour
of accident/Awareness
of illness
Date and hour reported
to employer
dd
mm
AM 2. Who did you report this accident/illness to? (Name & Position)
PM
yy
AM
PM
(
Telephone
)
3. Area of Injury (Body Part) - (Please check all that apply)
Head
Face
Eye(s)
Ear(s)
Teeth
Neck
Chest
Right
Left
Upper back
Lower back
Abdomen
Pelvis
the employer's property or work site?
5. Did it happen outside the Province
of Ontario?
6. Have you hurt this area(s) of your
body before?
Wrist
Hand
Finger(s)
Are you:
Other:
4. Did the accident/illness happen on
Right
Left
Shoulder
Arm
Elbow
Forearm
Left
Right
Left Handed
Right
Left
Hip
Thigh
Knee
Lower Leg
Ankle
Foot
Toe(s)
Right handed
Specify where it happened (shop floor, warehouse, client/customer site, parking lot, etc.):
yes
no
yes
no
If yes, indicate where
(city, province/state, country):
yes
no
7. Do you have any prior
related WSIB/WCB claims?
no
yes - In Ontario
yes - Outside Ontario
A guide to complete this form is available at
0006A (07/05)
Page 1 of 4
next page
6
Worker Name - Last Name
Worker's Report
Claim Number
First Name
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.
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.
D. Health Care Information
1. Did you get first aid
yes
or care at work
Give your Health Professional your WSIB Claim number.
no
dd
If yes, when
mm
yy
and by whom (Name):
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
Station
Emergency
Department
Admitted to
Hospital
Ambulance
Health
Professional Office
Clinic
3. Were you prescribed any medications/drugs?
yes
4. Were you referred for any other treatment or tests?
no
5. Did you talk to your health professional about going back to
yes
regular or modified work?
6. Did you tell your employer you went for medical treatment?
dd
If yes, when?
Date of Visit (dd/mm/yy)
mm
yy
yes
no
no
If yes, were you given
any work limitations?
yes
yes
no
no
If no, please tell your employer right away.
Name
and to whom?
Position
0006A (07/05)
Page 2 of 4
next page
6
Worker's Report
Claim Number
First Name
E. Lost Time & Return to Work
1. After the day of accident/illness:
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 (e.g. regular pay, shift differential, bonuses, premiums, etc.).
u Date you first lost time and/or pay
2. If you lost time, have you returned to work?
yes
dd
If yes
u
Date of your return to work
If no
u
Did you discuss return to work with
your employer?
dd
mm
yy
no
mm
yy
regular work
yes
modified work
Does your employer have modified work?
no
yes
no
F. Earnings (Do not include overtime here)
1. Rate of pay: $
2. Usual number of pay hours:
per
hour
week
per
week
other:
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
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?
G. Declarations and Signature
By signing below, you are claiming benefits under the Workplace Safety and Insurance Act, 1997, for a work-related injury or disease. When you make a claim for
benefits, you must consent to disclose your functional abilities information. Your consent allows your health professional to release information about your functional
abilities directly to your employer in addition to the WSIB.
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.
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.
Signature
Date (dd/mm/yy)
Relationship:
Telephone
(
)
Personal information about you will be collected throughout your claim under the authority of the Freedom of Information and Protection of Privacy Act and
will be used to administer the Workplace Safety and Insurance Act, 1997, your claim and programs of the Board. Medical and non-medical information is
collected from health care providers, vocational agencies, labour market service providers, employers, witnesses, and others as required. Your Social
Insurance Number is used to register claims, identify workers and to issue income tax receipts and is collected under the authority of the Income Tax Act.
Information may only be disclosed to the employer, external medical, vocational, and safety agencies, external payment and service providers, researchers,
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 party researchers conducting satisfaction surveys and focus groups. Questions should be directed to the decision maker
responsible for your file or toll free at 1-800-387-5540.
A more detailed PRIVACY STATEMENT for workers may be found at
0006A (07/05)
or by calling toll free at 1-800-387-5540.
Page 3 of 4
next page
6
Worker's Report
Claim Number
First Name
K. Additional Information
0006A (07/05)
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
home
Page 4 of 4
Did you know that you
can securely file Form 7
online with our eServices?
eForm7 offers a fast, effective solution for
managing your Form 7 reports with the WSIB.
To submit an eForm 7, visit our eServices site. It
only takes a few minutes to subscribe and you can
start filing your reports right away.
If you have any questions, you can call our
eServices Support Centre, Monday to Friday from
8:30am – 4:30pm, at 1-866-542-9742 to speak to
an eForms Representative.
reset
print
Mail To:
Toronto ON M5V 3J1
Reset
Print
OR Fax To:
416-344-4684
reset
OR 1-888-313-7373
7
Reset This
Page
reset
this
Reset
page
A. Worker Information
Reset This
Page
this
Job Title/Occupation (at the time of accident/illness - do not reset
usepage
abbreviations)
Please check if this worker is a:
executive
Last Name
elected official
owner
Claim Number
spouse or relative of the employer
Address (number, street, apt., suite, unit)
Province
Length of time in this position
while working for you
First Name
City/Town
Employers Report
Is the worker covered by a
Union/Collective Agreement?
yes
no
Workers preferred language
English
French
Other
Worker Reference Number
Sex
Date of
Hire
Postal Code
F
M
dd
Date of
Birth
Telephone
mm
yy
dd
mm
yy
Fold here for
#10 envelope
B. Employer Information
Trade and Legal Name (if different provide both)
Check
one:
Mailing Address
858
City/Town
Province
Postal Code
Oshawa
Ont
L1H 3Y1
Description of Business Activity
Does your firm have 20 or
more workers?
■ yes
Branch Address where worker is based (if different from mailing address - no abbreviations)
City/Town
Province
C. Accident/Illness Dates and Details
dd
mm
yy
1. Date and hour of
AM
PM
accident/Awareness
of illness
Date and hour reported
to employer
dd
Account Provide Number
Number
223718CT
Classification Unit Code
Firm OR
■ Number
Rate Group Number
mm
yy
3. Was the accident/illness:
8624-0000
Telephone
( 905 )
FAX Number
no ( 905 )
576-3011
576 9754
Alternate Telephone
(
)
Postal Code
2. Who was the accident/illness reported to? (Name & Position)
Telephone
(
)
AM
PM
Ext.
4. Type of accident/illness: (Please check all that apply)
Sudden Specific Event/Occurrence
Gradually Occurring Over Time
Occupational Disease
Fatality
Fall
Harmful Substances/Environmental
Assault
Other
Struck/Caught
Overexertion
Repetition
Fire/Explosion
Slip/Trip
Motor Vehicle Incident
5. Area of Injury (Body Part) - (Please check all that apply)
Head
Face
Eye(s)
Ear(s)
Other
Teeth
Neck
Chest
Upper back
Lower back
Abdomen
Pelvis
Right
Left
Shoulder
Arm
Elbow
Forearm
Right
Left
Wrist
Hand
Finger(s)
Left
Right
Right
Left
Hip
Thigh
Knee
Lower Leg
Ankle
Foot
Toe(s)
6. Describe what happened to cause the accident/illness and what the worker was doing at the time (lifting a 50 lb. box, slipped on wet floor, repetitive movements,
etc. . .). Include what the injury is and any details of equipment, materials, environmental conditions (work area, temperature, noise, chemical, gas, fumes, other
person) that may have contributed. For a condition that occurred gradually over time, please attach a description of the physical
activity required to do the work.
0007A (11/05)
A guide to complete this form is available at
next page
Page
Page
1 of1 3of 4
7
Worker Name
Employers Report
Claim Number
C. Accident/Illness Dates and Details (Continued)
Specify where (shop floor, warehouse, client/customer site, parking lot, etc..).
7. Did the accident/illness happen on the employers
premises (owned, leased or maintained)?
yes
no
8.
Did the accident/illness happen outside the Province
of Ontario?
yes
no
If yes, where (city, province/state, country).
9.
Are you aware of any witnesses or other employees
involved in this accident/illness?
yes
If yes, provide name(s), position(s), and work phone number(s).
no 1.
2.
If yes, please provide name and work phone number
10. Was any individual, who does not work for your firm,
partially or totally responsible for this
accident/illness?
yes
no
If yes, please explain
11. Are you aware of any prior similar or related problem,
injury or condition?
yes
no
12. If you have concerns about this claim, attach a written submission to this form.
D. Health Care
1. Did the worker receive health care for this injury?
yes
no
If yes, when :
dd
mm
yy
submission attached
dd
2. When did the employer learn that the worker
mm
yy
received health care?
3. Where was the worker treated for this injury? (Please check all that apply)
On-site health care
Ambulance
Emergency department
Admitted to hospital
Health professional office
Clinic
Other:
Name, address and phone number of health professional
or facility who treated this worker (if known)
E. Lost Time - No Lost Time
1. Please choose one of the following indicators. After the day of accident/awareness of illness, this worker:
Returned to his/her regular job and has not lost any time and/or earnings. (Complete sections G and J).
Returned to modified work and has not lost any time and/or earnings. (Complete sections F, G, and J).
Has lost time and/or earnings. (Complete ALL remaining sections).
Provide date worker first lost time
dd
mm
yy
Date worker returned to work (if known)
2. This Lost Time - No Lost Time - Modified Work information was confirmed by:
Myself
limitations for this workers injury?
(
yes
no
discussed with this worker?
yes
no
mm
yy
Telephone
Other
Name
F. Return To Work
1. Have you been provided with work 2. Has modified work been
dd
Ext.
)
3. Has modified work been
If yes, was it
offered to this worker?
yes
regular work
modified work
Accepted
Declined
If Declined please attach a copy of
the written offer given to the worker.
no
4. Who is responsible for arranging workers return to work
Myself
0007A (11/05)
Other
Name
Telephone
(
Ext.
)
next page
Page22of
of 34
Page
Employers Report
7
Worker Name
Claim Number
G. Base Wage/Employment Information - (Do not include overtime here)
1. Is this worker (Please check all that apply)
Permanent Full Time
Permanent Part Time
Temporary Full Time
Temporary Part Time
2. Regular rate of pay
Casual/Irregular
Seasonal
Contract
$
per
Owner Operator or
(Sub) Contractor
Registered Apprentice
Optional Insurance
Student
Unpaid/Trainee
Other
hour
day
week
other
H. Additional Wage Information
1. Net Claim Code
2. Vacation pay
or Amount
Federal
3. Date and hour last worked
dd
mm
- on each cheque?
Provincial
4. Normal working hours on
last day worked
From
yy
5. Actual earnings for
yes
Provide
percentage
%
6. Normal earnings for
last day worked
To
AM
PM
Is the worker being paid while he/she recovers?
no
last day worked
AM
PM
7. Advances on wages:
yes
no
AM
PM
$
$
Full/Regular
If yes, indicate:
Other
8. Other Earnings (Not Regular Wages): Provide the total of additional earnings for each week for the 4 weeks before the accident/illness.
* For Rotational Shift workers - If the shift cycle exceeds 4 weeks,
Use these spaces for any other earnings
Commission, Differentials, Premiums,
(indicate
Bonus, Tips, In Lieu %, etc..).
please attach the earnings information for the last complete shift
cycle prior to the date of accident/illness.
Period
From Date
(dd/mm/yy)
To Date
(dd/mm/yy)
Mandatory
Overtime Pay
Voluntary
Overtime Pay
Commission
Commission
Commission
Commission
$
$
$
$
$
$
Week 3
$
$
$
$
$
$
$
$
$
$
$
$
Week 4
$
$
$
$
$
$
Week 1
Week 2
I. Work Schedule (Complete either A, B or C. Do not include overtime shifts)
(A.) Regular Schedule - Indicate normal work days and hours.
Sunday
Monday
Tuesday
Wednesday Thursday
Example: Monday to Friday, 40 hours
Friday
S
Saturday
M T W
8 8 8
T
8
F
8
S
or,
(B.) Repeating Rotational Shift Worker - Provide
NUMBER OF
DAYS ON
NUMBER OF
DAYS OFF
HOURS
PER SHIFT(s)
NUMBER OF WEEKS
IN CYCLE
Example:
4
days
on,
4
days
off,
12
hours
per
shift,
8
weeks
in cycle.
or,
(C.) Varied or Irregular Work Schedule - Provide the total number of regular hours and shifts for each week for the 4 weeks
prior to the accident/illness. (Do not include overtime hours or shifts here).
Week 3
Week 4
Week 1
Week 2
From/To Dates (dd/mm/yy)
/
/
/
/
Total Hours Worked
Total Shifts Worked
J. 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.
Name of person completing this report (please print)
Official title
Signature
Telephone
(
Ext.
Date
dd
mm
yy
)
THE WORKPLACE SAFETY AND INSURANCE ACT REQUIRES YOU GIVE A COPY OF THIS FORM TO YOUR WORKER
0007A (11/05)
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K. Additional Information
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THE WORKPLACE SAFETY ANDHome
INSURANCE ACT
REQUIRES YOU GIVE A COPY OF THIS FORM TO YOUR WORKER
0007A (11/05)
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Community Living Oshawa/Clarington (CLOC) HUMAN

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