| Page 3 Specific part(s) of body injured:______________________________________________________________ _______________________________________________________________________________________ What is your doctors diagnosis?____________________________________________________________ ______________________________________________________________________________________ Work Will you lose any time from work due to the injury? Yes ______ No _______ If yes please list dates and time if known___________________________________________________ ____________________________________________________________________________________ How does the injury affect your return to work?_____________________________________________ ____________________________________________________________________________________ Please provide any other information you feel would be helpful.__________________________________ ____________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ For Union Purposes Only Has the company sent in a Form 7? Yes ______ No______ Copy to Worker Yes ____ No____ Claim Number____________________Has the claim been allowed? Yes ___ No _____ If yes were benefits paid and for how log?___________________________________________ ______________________________________________________________________________ If no, why was the claim disallowed?_________________________________________________ ______________________________________________________________________________ Has authorization been signed? Yes _____ No_____ What time limit to appeal is applicable?_________________ WSIB Decision Date:_______________________________ WSIAT Decision Date:_____________________________ List comments on separate page. Home |