Fill and Sign the Ncu Transcript Form

Employee Injury/Accident Report Form Personal information collected on this form is collected for the purposes of generating injury related statistics for the employer and in accordance with the Worker’s Compensation Act, the submission of a worker’s claim for compensation Instructions for Injured Worker Step 1 Complete the Employee Injury/Accident Report Form Ä Immediately fax the completed form to DMI Ä 604-552-3648 or Toll Free at 1-866-963-9994 Step 2 Inform your supervisor of the accident Ä Fax or forward the completed form to Maintenance: Attention Roy Paul Ä 604-792-5220 If you require additional space for comments: Please use a separate sheet of paper and submit with the Employee Injury/Accident Report Form Please Print SECTION A: EMPLOYEE’S REPORT School of Work Site Chilliwack School District Last Name First Name Phone Address (No, St, Apt) City/Town Postal Code Birth Date (MM/DD/YY) Date of Employment Work Phone & Local SIN (Only if you see a Dr or lose time from work) Position/Occupation Date/Time Reported Reported to Injury Date (MM/DD/YY) Time Describe How and Where the Incident/Accident Happened Describe (in detail) Your Injured Body Part (incl. right or left) Were you injured? Yes No Did/will you seek first aid? Yes No Did/will you see a doctor? Yes No Did you/will you lose time from work beyond the date of injury? Yes Name of Witness Doctor/Clinic Name Did/will you go to Emergency? Yes No No Have you had any previous incidents causing similar pain or discomfort? Yes No Name of Supervisor I declare all the information I have given on this report is true and correct and I elect to claim compensation for the above mentioned injury(s) or disease(s). I authorize the Worker’s Compensation Board (the Board) and Review Board to obtain or view, from any source whatsoever, including records of physicians, qualified practitioners, medical insurers or hospitals, a copy of records pertaining to examination, treatment, history and employment of the undersigned. Further, I acknowledge that the Board may disclose information from my claim to my employer for the purposes of appeal, or may disclose such information to others in accordance with the law, including the Freedom of information and Privacy Act and the Personal Information Privacy Act. I authorize the Board to disclose information from my claim to the designated advocate of my union or similar association. I understand it is a serious offense to knowingly make a false claim or to work and earn income while receiving compensation without advising the Board . Signature of Injured Employee: Date ______________________________Month / Day / Year IMMEDIATELY FAX THE COMPLETED FORM TO DMI AT 604-552-3648 OR 1-866-963-9994 AND MAINTENANCE AT 604-792-5220