Worker's Injury Report (WCB Form 6a)

Use this form when instructed by Health and Safety to report incident details

Title

A short description to explain the nature of a ticket.

Worker's Report of Injury to Employer (WCB Form 6a)

Introduction:

Please complete this form if you have lost time or received medical aid (treatment or service from a qualified doctor or health care provider) for an injury, illness, or exposure related to the workplace. WorkSafeBC requires both the worker and the employer to report any workplace injuries, illness, or exposures requiring medical aid. This report should be submitted within 24 hours of receiving medical aid.

Have you reported your injury, illness, or exposure to WorkSafeBC

Yes

No (call the WorkSafeBC Teleclaim number at 1-888-967-5377 to report your injury)

Name:

Date of Birth:

Mailing Address:

Home Phone Number:

Social Insurance Number

Personal Health Number

Position/Job Title:

Date and Time of Injury, Illness, or Exposure

Date and Time Reported

Reported To:

Location where incident occurred (campus, building, room #, area, etc.)

Description of how the injury, illness, or exposure occurred (what happened)

Description of injury, illness, or exposure

Name of witnesses

Were your actions at the time of injury related to your work?

Were you performing regular duties at the time of the incident?

Have you experienced any recent pain or disability in the area of injury?

Did you miss any time from work beyond the date of injury, illness, or exposure?

Have you returned to work?

Return to work date:

Other Fields

Your name

Your email address