Employer's Report of Injury/Disease

About this form

A form Ontario employers must submit to the WSIB within 3 days when a worker is injured or develops an occupational disease.

A form Ontario employers must submit to the WSIB within 3 days when a worker is injured or develops an occupational disease.

Who needs this form

All Ontario employers (legal obligation when a worker is injured or develops an occupational disease)

What's in this form

• Employer information (company name, address, WSIB account number)
• Injured worker information
• Accident/disease details (date, time, location, description)
• Nature of injury and body part affected
• First aid and medical treatment
• Work hours and wage information
• Witness information

Published by

Workplace Safety and Insurance Board (WSIB)