| Local Union Workers' Compensation Fact Reporting Form Workers Name:______________________________________ Injury Date:_________________________________________ Workers Address____________________________________ Home Phone:_______________Work Phone______________ Name of your steward:_______________________________ Social Insurance Number________________Dare of Birth ______________ Family Doctor____________________________Phone_________________ Address_______________________________________________________ Specialist________________________________Phone_________________ Address:______________________________________________________ Injury History Time and Date of Injury: Day______ Month______ Year_______ Time______ Time and Date Injury Reported Day_______ Month ______ Year______ Time______ Who was the injury reported to ______________________________________________ (name and position) How does the injury effect your return to work?_________________________________ ________________________________________________________________________ Explain fully how the injury occurred__________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Explain fully how the injury occurred_________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ go to page 2 |