Whscc Form 7 Employers Report Of Injury Page 2
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Page 2 of 2 – March 2013
Worker’s name
Social Insurance Number
SECTION D - RETURN-TO-WORK INFORMATION
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Did the worker stop working?
What is the worker’s current return-to-work status?
Yes
No
Returned to pre-injury job with no changes
yyyy/mm/dd
hh:mm
AM
Returned to pre-injury job with duties only changed
When?
PM
Returned to pre-injury job with hours only changed
yyyy/mm/dd
Returned to pre-injury job with duties and hours changed
Has the worker
Yes
When?
since returned
Returned to work in a different job to accommodate injury
Has the worker been offered
No
to work?
Yes
No
alternate / modified duties?
Other accommodations
specify
16
Has an early and safe return-to-work (ESRTW) plan been completed?
Yes
No
Attach plan or forward within five days
SECTION E - EARNINGS INFORMATION
Complete only if claim involves lost-time / ESRTW greater than the day of injury.
17
If the worker has not returned to work in any capacity,
Are you paying 80% of net?
Yes
Yes
are you continuing to pay the worker directly
Provide date
No
The employer cannot pay
No
yyyy/mm/dd
worker stopped
during the lost-time period?
the worker an amount in
receiving wages
The employer must pay worker for day of injury.
excess of compensation entitlement.
18
Showing separately for each week or pay period, indicate the worker’s gross wages for the four pay periods before lost-time or ESRTW:
include bonuses, overtime, and periods without pay
To
Wages
Lost-time
Period from
Holidays
Illness
Lack
$
¢
yyyy
yyyy
mm
dd
mm
dd
without pay
of work
without pay
.
Days
Days
Days
1.
.
2.
Days
Days
Days
.
Days
Days
Days
3.
.
4.
Days
Days
Days
Next pay day
yyyy/mm/dd
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Worker’s regular
Frequency
Weekly
Bi-weekly
Monthly
Semi-monthly
hourly rate:
of pay:
20
Indicate on this 14-day chart the hours per day the worker would work:
Sun
Mon
Tue
Wed
Thur
Fri
Sat
1.
Week 1
2.
Week 2
If the worker is a shift worker, how many shifts did they lose as a result of the injury / incident?
SECTION F - FISHER’S INFORMATION
To be completed by master, owner or part owner of a fishing vessel.
21
Vessel name
Vessel length (feet)
Is the worker an owner or
Yes
No
part owner of the vessel?
Master’s name
Master’s telephone
Master’s mailing address
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City/Town
Province
Postal code
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Yes
No
Are the worker’s earnings based on a share of the catch?
If yes, describe the worker’s share arrangement: __________________________________________
Fish buyer’s information
If you need more space, please use an additional sheet.
Start of fishing period End of fishing period
Name
Telephone
Fax
Gross sales
yyyy/mm/dd
yyyy/mm/dd
1.
2.
3.
Attach pay stubs or other verification from the fish buyer, if available.
SECTION G - INFORMATION ACCESS AUTHORIZATION
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Do you authorize another individual outside your organization or company
This authorization will remain in effect until you notify the
No
Yes
Commission of a change using Form 13.
to act on your behalf and access employer information regarding this claim?
Last name
First name
Address
Organization
Telephone
if applicable
SECTION H - SIGNATURE, CONSENT AND DECLARATION
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I declare this form to be complete and correct. I understand that giving false information or omitting relevant information is a serious of fence.
Name
Position
Signature
Telephone
Date
yyyy/mm/dd
please print
SECTION I - CO-OPERATION AND OBLIGATION
WHSCC USE ONLY
This form must be filed within three days of the injury Late and incomplete reports may result in a fine All employers and workers
must co-operate in early and safe return to work A re-employment obligation may exist if there are 20 or more workers in your
employment and if you continuously employed the injured worker for more than one year The Occupational Health and Safety Act
requires that all incidents resulting in serious injury be reported to the Occupational Health and Safety Branch at (709) 729-4444.
If attaching additional information, put the worker ’s first name, last name and Social Insurance Number at the top of each sheet.
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