1. No category

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Mail To:
200 Front Street West
Toronto ON M5V 3J1
OR Fax To:
416-344-4684
OR 1-888-313-7373
7
Please PRINT in black ink
A. Worker Information
Job Title/Occupation (at the time of accident/illness - do not use abbreviations)
executive
Last Name
elected official
Address (number, street, apt., suite, unit)
Province
Claim Number
Social Insurance Number
spouse or relative of the employer
owner
First Name
City/Town
of Injury/Disease (Form 7)
Length of time in this position
while working for you
Start >
Please check if this worker is a:
Employer's Report
Is the worker covered by a
Union/Collective Agreement?
yes
no
Worker's preferred language
English
French
Other
Worker Reference Number
Sex
Date of
Hire
Postal Code
F
M
dd
Date of
Birth
Telephone
mm
yy
dd
mm
yy
Fold here for
#10 envelope
B. Employer Information
Trade and Legal Name (if different provide both)
Check
one:
Account Provide Number
Number
Classification Unit Code
Firm OR
Number
Rate Group Number
City/Town
Province
Description of Business Activity
E
Mailing Address
Postal Code
PL
Does your firm have 20 or
more workers?
yes
?
Telephone
FAX Number
no
Branch Address where worker is based (if different from mailing address - no abbreviations)
Province
C. Accident/Illness Dates and Details
dd
mm
yy
1. Date and hour of
accident/Awareness
of illness
3. Was the accident/illness:
dd
mm
yy
AM
PM
Alternate Telephone
2. Who was the accident/illness reported to? (Name & Position)
Telephone
SA
Date and hour reported
to employer
Postal Code
M
City/Town
AM
PM
Ext.
4. Type of accident/illness: (Please check all that apply)
sample
Sudden Specific Event/Occurrence
Fall
Harmful Substances/Environmental
Assault
Other
Struck/Caught
Overexertion
Repetition
Fire/Explosion
Gradually Occurring Over Time
Occupational Disease
Fatality
Slip/Trip
Motor Vehicle Incident
5. Area of Injury (Body Part) - (Please check all that apply)
Head
Face
Eye(s)
Ear(s)
Other
Teeth
Neck
Chest
Upper back
Lower back
Abdomen
Pelvis
Right
Left
Shoulder
Arm
Elbow
Forearm
Right
Left
Left
Wrist
Hand
Finger(s)
Right
Hip
Thigh
Knee
Lower Leg
Right
Left
Ankle
Foot
Toe(s)
6. Describe what happened to cause the accident/illness and what the worker was doing at the time (lifting a 50 lb. box, slipped on wet floor, repetitive movements,
etc. . .). Include what the injury is and any details of equipment, materials, environmental conditions (work area, temperature, noise, chemical, gas, fumes, other
person) that may have contributed. For a condition that occurred gradually over time, please attach a description of the physical
activity required to do the work.
0007A (01/11)
A guide to complete this form is available at www.wsib.on.ca
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Page
of 34
Page 11 of
7
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Please PRINT in black ink
Worker Name
Employer's Report
of Injury/Disease (Form 7)
Claim Number
Social Insurance Number
C. Accident/Illness Dates and Details (Continued)
Specify where (shop floor, warehouse, client/customer site, parking lot, etc..).
7. Did the accident/illness happen on the employer's
premises (owned, leased or maintained)?
Start >
yes
no
8.
Did the accident/illness happen outside the Province
of Ontario?
yes
no
If yes, where (city, province/state, country).
9.
Are you aware of any witnesses or other employees
involved in this accident/illness?
yes
If yes, provide name(s), position(s), and work phone number(s).
no 1.
2.
partially or totally responsible for this
accident/illness?
yes
no
If yes, please explain
11. Are you aware of any prior similar or related problem,
injury or condition?
no
PL
yes
E
If yes, please provide name and work phone number
10. Was any individual, who does not work for your firm,
12. If you have concerns about this claim, attach a written submission to this form.
D. Health Care
1. Did the worker receive health care for this injury?
yes
no
If yes, when :
dd
mm
yy
submission attached
dd
2. When did the employer learn that the worker
mm
yy
M
received health care?
3. Where was the worker treated for this injury? (Please check all that apply)
On-site health care
Ambulance
Admitted to hospital
Health professional office
Clinic
SA
Other:
Emergency department
Name, address and phone number of health professional
or facility who treated this worker (if known)
E. Lost Time - No Lost Time
1. Please choose one of the following indicators. After the day of accident/awareness of illness, this worker:
Returned to his/her regular job and has not lost any time and/or earnings. (Complete sections G and J).
Returned to modified work and has not lost any time and/or earnings. (Complete sections F, G, and J).
Has lost time and/or earnings. (Complete ALL remaining sections).
υProvide date worker first lost time
dd
mm
yy
υ Date worker returned to work (if known)
2. This Lost Time - No Lost Time - Modified Work information was confirmed by:
Myself
limitations for this worker's injury?
yes
no
discussed with this worker?
yes
no
mm
yy
Telephone
Other
Name
F. Return To Work
1. Have you been provided with work 2. Has modified work been
dd
3. Has modified work been
yes
Ext.
If yes, was it
offered to this worker?
no
regular work
modified work
Accepted
Declined
If Declined please attach a copy of
the written offer given to the worker.
4. Who is responsible for arranging worker's return to work
Myself
0007A (01/11)
Other
Name
Telephone
Ext.
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Page
7
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Please PRINT in black ink
Worker Name
Employer's Report
of Injury/Disease (Form 7)
Claim Number
Social Insurance Number
G. Base Wage/Employment Information - (Do not include overtime here)
1. Is this worker (Please check all that apply)
Start >
Casual/Irregular
Seasonal
Contract
Permanent Full Time
Permanent Part Time
Temporary Full Time
Temporary Part Time
2. Regular rate of pay
$
per
Owner Operator or
(Sub) Contractor
Registered Apprentice
Optional Insurance
Student
Unpaid/Trainee
Other
hour
day
week
other
H. Additional Wage Information
1. Net Claim Code
2. Vacation pay
Federal
3. Date and hour last worked
dd
mm
- on each cheque?
Provincial
4. Normal working hours on
last day worked
From
yy
5. Actual earnings for
yes
last day worked
AM
PM $
If yes, indicate:
no
Full/Regular
%
6. Normal earnings for
To
AM
PM
Is the worker being paid while he/she recovers?
Provide
percentage
no
last day worked
AM
PM
7. Advances on wages:
yes
$
E
or Amount
Other
PL
8. Other Earnings (Not Regular Wages): Provide the total of additional earnings for each week for the 4 weeks before the accident/illness.
* For Rotational Shift workers - If the shift cycle exceeds 4 weeks,
Use these spaces for any other earnings
Commission, Differentials, Premiums,
θ (indicate
Bonus, Tips, In Lieu %, etc..).
please attach the earnings information for the last complete shift
cycle prior to the date of accident/illness.
Period
From Date
(dd/mm/yy)
To Date
(dd/mm/yy)
$
Voluntary
Overtime Pay
Commission
Commission
Commission
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
SA
Week 3
Commission
$
$
M
Week 1
Week 2
Week 4
Mandatory
Overtime Pay
I. Work Schedule (Complete either A, B or C. Do not include overtime shifts)
(A.) Regular Schedule - Indicate normal work days and hours.
Sunday
Monday
Tuesday
Wednesday Thursday
or,
υ Example: Monday to Friday, 40 hours
Friday
S
Saturday
M T W
8 8 8
T
8
F
8
S
(B.) Repeating Rotational Shift Worker - Provide
NUMBER OF
DAYS ON
NUMBER OF
DAYS OFF
HOURS
PER SHIFT(s)
NUMBER OF WEEKS
IN CYCLE
Example:
4
days
on,
4
days
off,
12
hours
per
shift,
8
weeks
in cycle.
υ
or,
(C.) Varied or Irregular Work Schedule - Provide the total number of regular hours and shifts for each week for the 4 weeks
prior to the accident/illness. (Do not include overtime hours or shifts here).
Week 3
Week 4
Week 1
Week 2
From/To Dates (dd/mm/yy)
/
/
/
/
Total Hours Worked
Total Shifts Worked
J. It is an offence to deliberately make false statements to the Workplace Safety and Insurance Board.
I declare that all of the information provided on pages 1, 2, and 3 is true.
Name of person completing this report (please print)
Official title
Signature
Telephone
Ext.
Date
dd
mm
yy
Please print form & sign before returning to the WSIB
THE WORKPLACE SAFETY AND INSURANCE ACT REQUIRES YOU GIVE A COPY OF THIS FORM TO YOUR WORKER
0007A (01/11)
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Page33 of
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Page
7
Please PRINT in black ink
Worker Name
Employer's Report
of Injury/Disease (Form 7)
Claim Number
Social Insurance Number
K. Additional Information
SA
M
PL
E
Start >
THE WORKPLACE SAFETY AND INSURANCE ACT REQUIRES YOU GIVE A COPY OF THIS FORM TO YOUR WORKER
0007A (01/11)
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Sample Letter to Health Professional
[Company letterhead]
[Date of letter]
[Health Professional’s name and address]
Subject: [Worker's name and date of injury]
Dear Dr. _____________:
[Company name] understands the importance of keeping injured and ill workers
connected to the workplace by avoiding prolonged absences from one’s normal roles,
which is detrimental to a person’s mental, physical and social well-being(Canadian
Medical Association).
[Company name] provides a Return to Work (RTW) Program that is designed to meet
the individual needs and functional abilities .The program is designed to return them
safely to suitable work as soon as possible. This may involve modifying the
individuals existing job, temporary alternative work or transitional return to work
activities.
Enclosed is a detailed job description for the regular job of the worker named above.
Using the information provided on the Functional Abilities Form, we will develop a
return to work plan based on your findings.
You will receive a copy of the return to work plan and together we will monitor your
patient’s progress throughout the duration of the return to work plan.
We will ensure that any assignment meets all requirements, and will consider rearranging work schedules around appointments if necessary.
If you require additional information about a possible work assignment or about our
RTW program, please call [company contact name and number].
Sincerely,
[Signature and title]
Return to Work Plan
The Workplace Safety and Insurance Act obligates employers to attempt to provide suitable
employment that is available and consistent with the worker’s functional abilities and that, when
possible, restores the worker’s pre-injury earnings. The corresponding obligation on workers is to
assist the employer to identify suitable employment that is available and consistent with their
functional abilities.
The starting point and overall goal should be the worker’s pre-injury job.
Return to Work Plan
Worker Name:
Claim #:
Pre-injury job (attach pre-injury job description):
Injury Date:
Pre-injury workplace location:
Return to Work Plan Details
Interim Return to Work Goal:
 Pre-injury job
 Pre-injury Accommodated
 Work Comparable
 Alternative Work
Final Return to Work Goal:
 Pre-injury job
 Pre-injury Accommodated
 Work Comparable
 Alternative Work
Area(s) of Injury:
Functional Abilities (what the worker can do):
Source of Functional Abilities:
 Functional Abilities Form (FAF)
 Other (Specify):
Date:
Is there an active treatment plan that impacts RTW?
 No
 Yes – Provide details:
 Other – Provide details:
List all duties worker can perform:
List all accommodations to be implemented:
Work Schedule
Wk
#
1
Work
period
Sep7-14
Days scheduled each week & # of hours per day
Sun Mon Tues Wed
Thur Fri
Sat
0
hours
4
5
6
7
8
0
Additional Comments
on Work Schedule
1
2
3
4
5
6
7
8
Worker and Employer Follow-up Date:
Specify how worker will be paid:
Worker will be paid for hours worked only Or,
Employer will pay full regular wages
If there are any concerns during the Work Schedule please discuss immediately and
contact the WSIB Case Manager if unable to resolve.
Worker Name: ______________________________________________
Worker signature: ____________________________________________
Supervisor Name: __________________________________________
Supervisor Signature: _______________________________________
Other Name: ______________________________________________
Other Signature: ___________________________________________
Date: _______________________________________________________
Return to Work Progress Report
_________________________________________________________________________
Date:
Worker:
Manager:
Anticipated Outcome(s): (as written in the Return to Work (RTW) Plan)
Did the RTW plan actions result in the anticipated outcome(s)?
Yes
No if no why?
Is the RTW plan still current?
Yes
No
if no why?
Next Steps: (e.g. continue, revise or close the existing RTW plan)
Next follow-up date:
Completed by:
Return to Work Closure / Evaluation Report
______________________________________________________________________________
This report is to be completed by both the manager/supervisor and worker, independently,
once the final outcome is achieved. Send completed forms to EHS Officer, Risk Management
Department.
Date:
Name:
What is the duration of Return to Work (RTW) Plan (from injury/illness report to final
RTW)?
What was the final outcome? (check all that apply).
Anticipated outcome?





Pre-injury job
Pre-injury Accommodated
Work Comparable
Alternative Work
Other
Comments:






Actual outcome?
Pre-injury job
Pre-injury Accommodated
Work Comparable
Alternative Work
Labour Market Re-entry
Other
What worked well in the return to work process?
What are the opportunities for improvement? (For example: what would you change about
the process if you could?)
Completed by:
Thank you for completing this form. Confidentiality of this information will be assured. If you
have any questions, please contact the EHS Officer.
Student Declaration of Understanding
Workplace Safety and Insurance Board or Private Insurance Coverage
For Students on Program Related Placements
Student coverage while on placement:
The government of Ontario, through the Ministry of Training, Colleges and Universities (MTCU), reimburses
WSIB for the cost of benefits it pays to Student Trainees enrolled in an approved program at a Training Agency
(university). Ontario students are eligible for Workplace Safety Insurance Board (WSIB) coverage while on
placements that are required by their program of study.
MTCU also provides private insurance through ACE-INA to students should their unpaid placement required by
their program of study take place with an employer who is not covered under the Workplace Safety and
Insurance Act and limited coverage where placements are arranged by their postsecondary institution to take
place outside of Ontario (international and other Canadian jurisdictions). However, students are advised to
maintain insurance for extended health care benefits through a Trent University student insurance plan or other
insurance plan.
Please be advised that Trent University will be required to disclose personal information relating to the unpaid
work placement and any WSIB claim or ACE-INA claim to MTCU.
This Agreement must be completed prior to the commencement of the work placement, signed to indicate the
Student Trainee’s acceptance of the unpaid work placement conditions and a copy provided to the Trent
University placement coordinator.
Declaration:
I have read and understand that WSIB or private insurance coverage will be provided through the Ministry of
Training, Colleges and Universities while I am on a placement as arranged by the university as a requirement
of my program of study.
I understand that all accidents sustained while participating in an unpaid work placement must be immediately
reported to the Placement Employer and my Trent University placement coordinator. An MTCU
Postsecondary Student Unpaid Work Placement Workplace Insurance Claim form must be completed in the
event of injury.
I understand the implications and have had any questions answered to my satisfaction.
Student Name:
Student Signature:
Program:
Date:
Organization:
Total Placement Hours
Visa Student?  Y
N

Parent/Legal Guardian’s Name (for student less than 18 years of age) please print:
Signature:
Rev: December 17, 2013
Date
Trent University
Page 1 of 1
Letter to Placement Employers
Process for Workplace Safety and Insurance Board coverage:
The Ministry of Training, Colleges and Universities (MTCU) has implemented a new streamlined
process for students enrolled in an approved Ontario university program that requires them to
complete placements in a workplace as part of their program of study.
The Government of Ontario, through the Ministry of Training, Colleges and Universities (MTCU), pays
the WSIB for the cost of benefits provided to Student Trainees enrolled in an approved program at
Trent University and participating in unpaid work placements with employers who are either
compulsorily covered or have voluntarily applied to have Workplace Safety and Insurance Board
(WSIB) coverage.
MTCU also covers the cost of private insurance with ACE-INA Insurance for Student Trainees
enrolled in an approved program at Trent University and participating in unpaid work placements with
employers that are not required to have compulsory coverage under the Workplace Safety and
Insurance Act.
The Workplace Educational Placement Agreement (WEPA) Form has been replaced by the
Postsecondary Student Unpaid Work Placement Workplace Insurance Claim Form. Placement
Employers and Training Agencies (universities) are not required to complete and sign the online
Postsecondary Student Unpaid Work Placement Workplace Insurance Claim Form for each
placement that is part of the student’s program of study in order to be eligible for WSIB coverage.
Instead, this form only needs to be completed when submitting a claim resulting from an on-the-job
injury/disease. Please note that universities will be required to enter their MTCU- issued Firm Number
in order to complete the online claim form.
The new claim form is posted on the Ministry’s public website at:
http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/FormDetail?OpenForm&ACT=RDR&TA
B=PROFILE&SRCH=&ENV=WWE&TIT=1352&NO=022-13-1352E (English)
or
http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/FormDetail?OpenForm&ACT=RDR&TA
B=PROFILE&SRCH=&ENV=WWF&TIT=1352F&NO=022-13-1352F (French)
Please note that all WSIB or ACE-INA Insurance procedures must be followed in the event of an
injury/disease.
Rev: December 17, 2013
Trent University
Page 1 of 2
Declaration
By signature of an authorized representative here under we confirm our understanding of our
responsibility to protect Student Trainees from health and safety hazards in our workplace by
providing a safe working environment, health and safety orientation prior to exposure of hazards
(attached checklist may be used) and appropriate supervision during their placement. We also
confirm our commitment to immediately report any workplace injuries or disease to the student’s
university and follow WSIB and ACE-INA reporting procedures found in the MTCU “Guidelines for
Workplace Insurance for Postsecondary Students of Publicly Assisted Institutions on Unpaid Work
Placements.”
Organization:
Date:
Title:
Signature:
Employer’s organization is covered under the Workplace Safety & Insurance Board?
Yes
No
A signed copy of this document is to be returned to the Trent University placement coordinator, prior
to the commencement of the work/education placement, and a copy is to be kept by the placement
employer.
Rev: December 17, 2013
Trent University
Page 2 of 2
PRE-PLACEMENT/FIELD TRIP DUE DILIGENCE CHECKLIST
This checklist may be used to identify unsafe exposures in facilities/locations where students may be required to
work, study or perform research activities and also to document safety measures in place to protect students
from exposure.
Organization
Name:
Equipment
Hand tools and
equipment
Will the student be working with hand tools or equipment?
(e.g. hammer, screwdriver, blades)
Portable power
tools and
equipment
Will the student be working with portable power tools or
equipment? If yes, has hearing protection been provided?
(e.g. drill, jig saw, rotary tools)
Mobile equipment
Will the student be working with or near mobile
equipment?
If the student will be utilizing mobile equipment, will
training be required and/or provided?
(e.g. forklift, pallet truck)
Stationary power
machines
Will the student be operating stationary power machines?
(e.g. drill press, band saw, table saw)
Electrical
Will the student be exposed to any electrical hazards in
the workplace?
(e.g. electrical panels, lighting, electrical wiring)
Compression
Will the student be working with anything under
compression, such as compressed gases or gas
cylinders?
Pressure systems
Will the student be working in proximity to pressure pipes
or steam boilers?
Human Factors
Harassment
Is there a policy on harassment that will be provided to the
student?
Violence
Are there situations where the student could be exposed
to violence? Could the student become a subject of
violence?
Working alone
Will the student be working alone?
(e.g. working alone in an office or building)
Shift work
Will the student be working shifts?
(e.g. working an irregular work schedule)
Computer Use
Will the student be working at a computer for the majority
of a typical work day?
Work stress
Will there be a high level of stress in the student’s work?
(e.g. work requiring constant alertness for long periods of
time, such as a security monitor, or work with high levels
of emotional stress such as working in an Emergency
Room)
Revision Date: December 17, 2013
Trent University
Y/N
or
N/A
If yes, please specify what
protective measures are in place.
Y/N
or
N/A
If yes, please specify what
protective measures are in place
Page 1
Musculoskeletal
Disorders (e.g.
Lifting, Repetitive
Actions)
Will the student be using the same muscles over and over
again or for a long time without taking time to rest,
exerting high amounts of force and/or required to work in
an awkward posture?
General
Housekeeping
Will the student work in uncluttered workspace with
minimal distractions?
(e.g. tidy work area)
Entrances, exits
and stairways
Will the student encounter passageways, entrances, exits
(especially fire) or stairways that are not clearly marked or
clear of obstructions?
Working at
Heights
Is the student going to be working at elevation that they
may be susceptible to falling from?
If so, is adequate fall protection equipment
provided/required?
Chemical
substances
Will the student use or be exposed to flammable,
corrosive, toxic or reactive chemicals?
(e.g. acetone, nitric acid, toluene, mineral spirits)
Biological
substances
Will the student have contact with any harmful
microorganisms?
Radiation
Will the student be exposed to harmful radiation?
(e.g. x-rays, lasers)
Restricted spaces
Will the student be in proximity to or working in restricted
space, trenches or confined spaces?
(e.g. man hole, silo)
Hot materials or
surfaces
Will the student have contact with hot materials or
surfaces?
(e.g. stove, soldering iron, torch, forging materials,
welding materials)
Ultraviolet light
(Sunlight)
Will the student spend any time working in the sun?
If so, for what duration?
Temperature
Will the student work in very cold or hot conditions?
(e.g. outdoors, kilns, refrigerated areas)
Noise
Will the student be exposed to excessive noise in the work
environment of 85 decibels or greater?
Air quality
Will the student be exposed to excessive dust, fumes or
gases?
(e.g. welding fumes, carbon monoxide)
Other (attach
additional sheet if
necessary)
Completed by:
Revision Date: December 17, 2013
Signature:
Trent University
Date:
Page 2
SAFETY ORIENTATION CHECKLIST
Placement Employer: This checklist may be used to document health and safety orientation provided to a
student(s) prior to exposure to any hazards in your workplace. This checklist, or another format documenting
orientation, must be returned to Trent University placement coordinator.
Student Name:
Student Number
Organization
Name:

COMPLETE DURING ORIENTATION
Name of immediate supervisor and Joint Health and Safety Committee representative (JHSC) or Safety
Representative
Worker/supervisor rights and responsibilities
Safe work procedures and operation of equipment
Use of Personal Protective Equipment (PPE)
Identification of restricted or prohibited areas, tools, equipment and machinery
Hazards in the workplace that may affect the student, how they’re controlled and how to deal with them
What to do and who to see if the student has a safety concern
What to do when there is a fire or other emergency (e.g., evacuation procedures)
Location of fire exits and fire extinguishers
Location of the first aid supplies, equipment, facilities:
▪ Names of staff responsible for first aid
▪ How to record first aid treatment
Procedures for reporting accidents and injuries
Workplace Hazardous Materials Information System (WHMIS)
Workplace policies and procedures on:
▪ Workplace Harassment
▪ Violence prevention
▪ Working in isolation
▪ Smoking/Drinking/Substance abuse
Location of other important information
▪ Materials Safety Data Sheet (MSDS)
▪ Joint Health & Safety Committee Minutes
▪ Instructions for safe operation of each piece of equipment (if applicable)
▪ Important telephone numbers
Other hazards covered during orientation should be documented and attached on an additional sheet.
Signatures
Supervisor Name
Signature
Student Signature
Revision Date: December 17, 2013
Date
Date
Trent University
Page 1