Yukon Workers' Compensation Health and Safety Board

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To ensure we can process the claim quickly, please complete this form as thoroughly as possible.

Fields marked in red are required.

Worker's Report of Injury/Illness

Worker's Name:

Gender:

What is your home address?

Home Telephone Number:

What is your home telephone number?

Work Telephone Number:

Do you have a direct telephone line at work?

Cell number:

Do you have a cell phone?

What is your primary email address? We’ll use this address to contact you.

What is your job?

What is your supervisor’s name?

Supervisor's telephone number:

What is your supervisor’s phone number?

Supervisor's cell number:

What is your supervisor’s cell phone number?

What is the name of your employer?

If you work for the Yukon Government, in what department?

What is the full mailing address of your employer?

Tell Us About Your Injury/Illness

Describe how you were injured.

Yukon Workers' Compensation Health and Safety Board

Staff (“adjudicators”) look at each claim to see if it qualifies, under the law, as an injury covered by workers’ compensation.

To qualify, each of the following must be true:

  1. You have to be a worker under our Act. In very general terms, this means you were working for an employer when the injury happened;
  2. You have to be working in an industry covered under our Act. There is a list of industries not covered by us, which includes employees of the Federal government and other federally regulated industries;
  3. You have to have an injury or illness;
  4. The injury or illness has to have been caused by your work duties, during work hours;
  5. The injury or illness must not have been deliberately self-inflicted.

If you were physically injured, identify what part of your body was injured.

Have you hurt this part of your body before?

If you had a similar injury before identify it here

Date of injury/illness:

If your injury/illness occurred over time, when did you first experience symptoms?

Provide the name of the person you initially reported your injury/illness to

When did you report the injury/illness?

What were your hours of work on the day of the injury/illness?

From:

To:

Was first aid given at the work site?

Were you doing work for the employer when the injury occurred?

Did the injury/illness happen on your employer’s premises?

Did you seek medical attention beyond first aid at the work site?

When?

Did you miss work after the date of injury/illness?

Have you returned to work?

If Yes, when?

Additional Options

Email a copy of this form to a third party?

Would you like to send a copy of your completed form to someone via email?

Signature, Consent and Declaration

I declare that the information provided is true and correct. I consent to the release from any source to the Yukon Workers' Compensation Health and Safety Board (YWCHSB) of any medical or employment information relevant to my claim. I consent to YWCHSB disclosing to healthcare providers, hospitals, physicians, my employers, other workers' compensation boards, and any other relevant third parties, all relevant information necessary to administer my claim in accordance with the law.

I acknowledge that the YWCHSB may collect information it considers relevant to my claim to determine benefit entitlement and that my social insurance number may be used for reporting to Canada Revenue Agency and collecting information from Canada Revenue Agency for the purpose of determining benefit entitlement in accordance with the law.

Today’s date: March 27, 2017

This information is collected, used and disclosed under the authority of the Workers' Compensation Act and the Access to Information and Protection of Privacy Act for the purposes of administering and enforcing the Workers' Compensation Act. For further information, please contact (867) 667-5645 or 1-800-661-0443.

After you submit this form a PDF version will be available for download.

Before submitting this form, please fill out all fields marked in red.